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11 

THE PRACTICE 



OF 



MEDICINE AND SURGERY, 



APPLIED TO THE 



DISEASES AND ACCIDENTS INCIDENT TO WOMEN. 



By W. H. BYFORD, A.M., M.D., 

PROFESSOR OF GYNECOLOGY IN RUSH MEDICAL COLLEGE, AND OF OBSTETRICS IN THE WOMAN' 
MEDICAL COLLEGE ; SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO J EX- 
PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY J 
EX-V T CE-PRESIDENT OF THE AMERICAN 
MEDICAL ASSOCIATION, ETC. 



AND 

HENRY T. BYFOKD, M.D., 



SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO ; GYNECOLOGIST TO ST. LUKE'S HOSPITAL 

PRESIDENT OF THE CHICAGO GYNECOLOGICAL SOCIETY ; MEMBER OF AMERICAN 

MEDICAL ASSOCIATION ; OF ILLINOIS STATE MEDICAL SOCIETY ; 

OF CHICAGO MEDICAL SOCIETY, ETC. 



FOUETH EDITION. 

REVISED, REWRITTEN AND VERY MUCH ENLARGED 

WITH 

THREE HUNDRED AND SIX ILLUSTRATIONS. 




PHILADELPHIA: 
P. BLAKISTON, SON & CO., 

No. 1012 Walnut Street. 
1888. 









■o^ 






COPYRIGHT, 1887, 

BY 

P. BLAKISTON, SON & CO. 



PREFACE TO THE FOURTH EDITION 



In no other branch of medicine or surgery has there been more 
rapid and greater advances made during the past few years than in 
gynaecology. This has necessitated a complete revision of my book, 
entailing the rewriting of many sections, the addition of much new 
material, and the consequent enlargement of the volume. 

The principal additions are the chapters on " Practical Observations 
upon the Anatomy and Physiology of the Female Pelvic Organs ; " 
"Examination of the Female Pelvic Organs" (three chapters); 
" Displacements of the Uterus " (three chapters) ; " Affections of the 
Ovaries " and " Fallopian Tubes ; " and the paragraphs upon "Oopho 
rectomy," " Tumor of the Broad Ligament," etc. 

While Chapter I is intended to supplement the general knowledge 
of anatomy and physiology obtained at the medical colleges, Chapters 
II and III are intended as a study of the anatomy and relation of 
the pelvic structures as they are encountered clinically. The value of 
a proper understanding of the anatomy, physiology and topography 
of these special organs cannot be overestimated, and it is hoped that 
this section will be found of service both to practitioner and student. 
The chapter on " Lacerations of the Perineum and Pelvic Floor " has 
been rewritten, with the end in view of enabling the young practitioner 
to treat these accidents with discriminating intelligence, instead, as is 
so often the case, of learning to carve all injured perinsea to suit one 
stereotyped operation. Chapters XXIX, XXX, and XXXI, on 
" Displacements of the Uterus " have been rewritten and Chapter 
XXXII revised with a similar intention. The chapters on the "Affec- 
tions of the Ovaries " and " Fallopian Tubes " have also been revised, 
and the subject of oophorectomy rewritten. 

New matter concerning tumor of the broad ligament and pelvic 
abscess (see chronic perimetritis) has been added, and some additions 
to Chapters III, XII, XXV, XXXV, XXXVI, XXXIX, XLVIII, and 
others, made. 



PREFACE. 



Some subjects, such, for instance, as cancer of the uterus, might 
have been more extensively revised, but it has been thought better, in 
view of the indefinite state of our knowledge upon them, to limit the 
alterations to correspond to that which is most settled and useful from 
a practical standpoint. 

The illustrations, over one hundred and fifty of which are new, have 
been carefully selected, a majority of them (excepting cuts of instru- 
ments) being from original drawings made especially for this edition. 

A large part of the work of revision and editing having been done 
by Henry T. Byford, M.D., I feel that an ordinary acknowledgment 
of his services would be inadequate; I, therefore, believe it only just 
to place his name on the title-page as one of the authors. Acknowl- 
edgment is also due to Dr. Eobert J. Hess, of Philadelphia, for his 
services in reading proof and preparing the indexes. 

We have endeavored throughout the book to give the proper credit 
to all workers in this field whenever referred to, but I wish here to 
render my general acknowledgment to all. 



W. H. B. 



Chicago, December, 1887. 



CONTENTS. 



CHAPTER I. 

PRACTICAL OBSERVATIONS UPON THE ANATOMY AND PHYSIOLOGY OF 
THE FEMALE PELVIC ORGANS. 

I. PELVIC ROOF, 18. Musculature of the pelvic roof, 19. Peritoneal 

covering of the pelvic roof, 22. Pelvic connective tissue, 23. The 
ovaries and their relations, 25. Ureters, 27. Vagina, 28. Plane of the 
pelvic roof, 31. Relation of uterus to bladder, 31. Relation of pelvic 
roof to pelvic floor, 32. 

II. THE PELVIC FLOOR, 32. Relation of the muscles of the pelvic 

floor and interposed tissues, 34. Abdominal pressure, 35. Requirements 
for the closure of the pelvic floor insufficiency, 38. 

III. PERINEUM, 39. Perineal body, 42. Measurements of the perineal 

body, 42. Characteristics of the perineal body, 43, Action of the 
perineum as a support, 44. The rectum, 46. The bladder, 50. The 
bloodvessels, 51. Nerves 53. Lymphatics, 53. 

CHAPTER II. 

EXAMINATION OF THE FEMALE PELVIC ORGANS. 

Position of patient for examination, 56. Percussion of the pelvic organs, 58. 
Palpation of pelvic roof — digital examination through the vagina, 58. 
Characteristics of the cervix uteri, 59. The virgin cervix, 59. The cervix 
uteri of the child-bearing woman, 59. The senile cervix, 60. Location of 
the cervix uteri, 61. Corpus uteri, 63. Palpation of the displaced 
uterus, 63. Palpation of the pregnant uterus, 64. Examination of 
the uterus during general anaesthesia, 65. Digital exploration of the 
pelvic roof through the vagina, 67. The advantages of a gentle 
touch, 67. When not to examine, 68. Precautions necessary during 
examination, 68. Difficulty of differentiating pelvic tissues by the touch, 68. 
The starting point in digital explorations of the pelvic roof, 69. How to 
palpate the ovaries, 69. Table of position of ovaries, 72. Palpation of the 
ovarian ligament, 72. The infundibulo-pelvic ligament, 73. Palpation of 
the round ligament, 74. Palpation of the Fallopian tubes, 77. Palpation 
of the ureters, 78. How to find the ureters with cervix in normal position, 
79. Palpation of the ureters when the cervix is displaced backward, 80. 
Palpation of the ureters when the cervix is displaced forwards, 80. Differ- 
entiation, 81, Palpation of the broad ligaments, 81. Vaginal palpation of 



VI CONTENTS. 

the sacro-uterine ligaments, 83. Palpation of the pubo-vesico-uterine 
ligament, 86. Palpation of the vagina, 88. Rectal examination of the 
pelvic roof, 90. Method of rectal indagation, 91. Digital exploration 
through the upper rectum, 93. The recto-vaginal grip, 95. Circumdigita- 
tion of the uterus from the abdomen, vagina and rectum, 95. Palpation of 
the interior of the bladder, 96. 

CHAPTER III. 

EXAMINATION OF THE FEMALE PELVIC OKGANS — CONTINUED. 

The pelvic floor and perineum, 98. Vaginal palpation of the pelvic floor, 98. 
The small sacro-sciatic ligament, and ischial spine, 99. The pyriformis, 99. 
The great sacro-sciatic foramen and sacral promontoiy, 100. The coccygeus, 
101. The levator ani, 101. Control of the pelvic floor muscles by will, 102. 
The obturator internus, 103. Rectal examination of the pelvic floor, 104. 
Palpation of the arteries of the pelvis, 104. Vaginal palpation of arteries, 
105. Rectal palpation of the pelvic arteries, 107. Palpation of pelvic 
nerves, 107. Examination of the perineum, 108. Examination of the 
vaginal orifice, 108. The levator vaginre and levator ani, 108. Examination 
of the vulval orifice, 110. The constrictor cunni or vulval sphincter, 111. 
The pubic fossa, 111. Transversus perinsei, 112. Characteristics of the 
perineal body, 112. Rectal palpation of the perineal body, 113. Digital 
eversion of the vagina, 113. 

CHAPTER IV. 

INSTRUMENTAL EXAMINATION OF THE FEMALE PELVIC ORGANS. 

Object in using the sound or probe, 114. Size and length of sound, 114. Mode 
of using, 117. Length of the cervical and uterine cavities, 117. Speculum, 
120. Position of patient for speculum, 121. Mode of using the speculum, 
122. How to find the os uteri, 123. Appearance of the os and cervix in 
the virgin, 125. Appearance of the multiparous uterus, 126. Appearance 
in the aged, 126. Exceptions to these appearances, 127. Color, 127. 
Appearance of secretion, 127. Indication of mucus in abundance, 127. 
Indication from pus, 128. Probe and speculum conjointly, 128. Dilata- 
tion, 128. Exploratory curetting of the uterus, 133. The use of the 
female catheter, 134. The urethral speculum and endoscope, 135. Cath- 
eterization of the ureters, 136. General manner of conducting an examina- 
tion in making a diagnosis, 138. 

CHAPTER V. 

DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

Wounds, 142. Sanguineous infiltration, 143. Varices of the labia and vulva, 

14:5. (Edema, 144. Phlegmon, 144. Abscesses of the labia, 146. 

Labial hydrocele, 146. Labial tumors, 147. Hypertrophied labia, 147. 
Cancer of the labia, 149. 



CONTENTS. VI 1 

CHAPTER VI. 

DISEASES OF THE VULVA. 

Condylomata of the vulva, 150. Treatment, 150. Inflammations, 150. Treat- 
ment, 151. Follicular vulvitis, 152. Causes, 152. Treatment, 152. 
Pruritus pudendi, 153. Treatment, 154. Corroding ulcer, 1 55. Gangre- 
nous vulvitis, or noma, 156. Urethral excrescences, 157. Vascular urethra, 
158. Hypertrophy of the clitoris and nynipha, 159. Treatment, 159. 

CHAPTER VII. 

LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

Preliminary observations* upon the conditions leading to injuries of the parturient 
canal, 160. The mechanism of laceration and injuries of the perineum and 
pelvic floor, 161. The sciatic and coccygeal surface, 161. Plane of obturato- 
coccygeus, 162. The levator coccygei, 163. The plane of the levator ani 
proper, 164. Plane of the levator vaginas or vaginal sphincter, 164. Plane 
of the constrictor cunni or vulval sphincter, 167. The vulval plane or ring, 
167. Lacerations extending into the transversus perinaei and sphincter 
ani, 168. Lacerations of the perineal septum, 168. Lacerations of the deep 
pelvic fascia, 168. The flap lacerations, 168. Central ruptures, 169. 
Irregular lacerations, 169. Concealed lacerations, 170. Contusions about 
the bony avails, 171. Lacerations extending into the rectum, 171. Effects 
of perineal and pelvic floor lacerations, 171. The immediate effects or those 
incident to the puerperal state, 171. Keruote effects, 172. Effects upon 
the uterus, 172. Effects upon the bladder, urethra, and rectum, 173. 
Effects upon the vagina, 174. Other effects, 174. Symptoms of perineal 
and pelvic floor lacerations, 174. Secondary symptoms, 174. Varieties of 
laceration, 175. Degrees of laceration, 176. Diagnosis of perineal and 
pelvic floor lacerations, 177. Palpations of old perineal lacerations, 180. 
Diagnosis by rectal palpation, 181: Diagnosis by inspection, 183. Combined 
palpation and inspection, 184. Diagnosis of old lacerations extending into 
the rectum, 184. Diagnosis of lacerations of the pelvic floor, 184. Deeper 
portions of the pelvic floor, 185. Method of diagnosis, 186. Prognosis, 
187. Prevention of lacerations, 187. Perineal incisions, 188. Colpotomy, 
189. Episiotomy, 189. Perineal tenotomy, 190. Delivery after perineal 
incisions, 192. Choice of methods, 192. After management, 193. 
Treatment of perineal lacerations, 193. Superficial lesions, 193. Treat- 
ment by coaptation, 193. Immediate perineorrhaphy, 194. Reasons for 
failure of the immediate operation, 194. Contraindications, 194. The 
operation, 195. Lacerations into the rectum, 199. Secondary perineor- 
rhaphy, 199. What is to be accomplished, 200. When to operate, 200. 
Methods of restoring the perineum when the rectum is not opened, 200. 
The median triangular operation, 200. The modified triangular operation, 
201. The bilateral operation, 202. Crescent operation, 204. Emmet's 
crescent operation, 205. Transverse denudations, 205. Star operation, 
205. Flap operations, 206. The triangular flap operation, 206. Bischoff 's 
operation, 207. Modified Freund's operation, 208. Crescentic flap opera- 



Vlll CONTENTS. 

tion, 208. Unilateral flap operation, 209. Operations upon uncicatrized 
lacerations, 210. Lacerations involving the sphincter ani but not the rectum, 
210. Closure of lacerations extending a short distance into the rectum, 
210. Flap operations, 211. Lacerations extending high up into the rectum, 
214. Choice of methods, 215. Preparation of the patient, 216. Prepara- 
tions for operating, 216. Operative detail, 217. Sutures, 218. The 
quilled suture, 219. Incision of sphincter ani, 221. After-treatment, 221. 

CHAPTER VIII. 

DISEASES OF THE BLADDER. 

Paralysis of the bladder, 223. Prognosis, 223. Symptoms, 223. Diagnosis, 
224. Treatment, 224. Hemorrhage from the bladder, 225. Hypersesthesia 
of the bladder and urethra — irritable bladder and urethra, 225. Causes, 
226. Treatment, 226. Chronic inflammation of the bladder, 227. Nature 
and progress, 227. Symptoms, 227. Diagnosis, 228. Prognosis, 228. 
Treatment, 228. Stone in the bladder, 231. Symptoms, 232. Diagnosis, 
232. Treatment, 233. Foreign bodies, 234. Inversion of the bladder, 
235. 

CHAPTER IX. 

AFFECTIONS OF THE VAGINA. 

Absence of the vagina, 236. Causes, 236. Diagnosis, 236. Atresia vaginae, 
237. Diagnosis, 237. Prognosis, 238. Treatment of atresia and absence 
of the vagina, 238. Tumors in the vagina, 240. Vaginismus, 241. Diag- 
nosis, 242. Prognosis, 242. Treatment, 242. Acute vaginitis, 243. 
Diagnosis, 244. Prognosis, 244. Cause, 244. Treatment, 244. Chronic 
vaginitis, 245. Symptoms, 245. Diagnosis, 246. Causes, 246. Prognosis, 
246. Treatment, 247. Puerperal vaginitis, 248. Symptoms, 249. Treat- 
ment, 250. Urinary fistula, 251. Diagnosis, 252. Prognosis, 253. 
Treatment, 254. Simon's method, 264. Kolpokleisis, 268. Bozeman's 
method, 271. Entero-vesical fistula, 274. Entero- vaginal fistula, 275. 
Rectovaginal fistula, 275. Treatment, 275. 

CHAPTER X. 

MENSTRUATION AND ITS DISORDERS. 

Puberty, 278. Amenorrhoea, 282. Pathology and morbid anatomy, 283. 
Symptoms, 283. Amenorrhoea from retention, 286. Diagnosis, 286. Diag- 
nosis of retention, 288. Prognosis, 289. Treatment, 290. 

CHAPTER XL 

MENORRHAGIA AND METRORRHAGIA. 

Treatment of menorrhagia, 300. Palliative treatment, 301. Curative treatment, 
304. 



CONTENTS. IX 

CHAPTER XII. 

DYSMENORRHEA. 

Diagnosis, 309. Prognosis, 309. Treatment, 309. The inflammatory form of 
dysmenorrhea, 310. Symptoms, 310. Diagnosis, 311. Prognosis, 311. 
Treatment, 311. Membranous dysinenorrhoea, 312. S3 T mptoms, 313. 
Diagnosis, 313. Treatment, 314. Obstructive dysnienorrhcea, 314. Symp- 
toms, 316. Diagnosis, 316. Prognosis, 317. Treatment, 317. Superficial 
trachelotomy — Peaslee's operation, 322. (a) Representing stenosis of the 
internal os, 322. (b) Representing stenosis of the external os, 323. 
Dilatation, 326. 

CHAPTER XIII. 

METATITHMENIA, OR MISPLACED MENSTRUATION. PERIUTERINE 

HEMATOCELE. 

Symptoms, 332. Diagnosis, 334. Prognosis, 335. Treatment, 336. Chronic 
Retrouterine Hematocele, 338. Diagnosis, 341. Treatment, 342. 

CHAPTER XIY. 

CHANGE OF LIFE MENOPAUSE AND SENILITY. 

CHAPTER XV. 

ACUTE INFLAMMATION OF THE UN IMPREGNATED UTERUS. 

Causes, 346. Symptoms, 346. Prognosis, 347. Diagnosis, 347. Treatment, 

348. 

CHAPTER XVI. 

GENERAL CONSIDERATIONS ON " UTERINE DISEASE," OR 
HYSTEROPATHY. 



CHAPTER XVII. 

SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

Sympathy of the stomach, 353. Sympathetic disease of the bowels, 354. 
Sympathetic affection of the liver, 354. Sympathetic affections of the ner- 
vous system, 355. Accompanying manifestations of moral and intellectual 
perverseness, 356. Syncopal convulsions — • hystero-epilepsy, 356. Moral 
and mental derangement. 357. Cephalalgia, 358. Affections of the spinal 
cord, 360. Hyperesthesia, 360. Anesthesia, 361. Spasms, 361. Sym- 
pathetic pains in the pelvic region, 361. Extension of inflammation to the 
bladder and rectum, 361. Affections of the sciatic and anterior crural 
nerves, 362. Muscular weakness, 362. Circulatory system, 363. Respi- 
ration, 364. S} T mpathy of the excretory organs, 365. Mammary bodies, 
366. 



X CONTENTS. 

LOCAL SYMPTOMS, 369. Pain in the sacral or lumbar region, 369. Pain 
in the loins, 370. Inability to walk, 370. Pain in the iliac region, 370. 
Soreness in the iliac region, 371. Pain in the side, above the ilium, 371. 
Weight, or bearing-down pain, or uterine tenesmus, 371. Leucorrhoea, 371. 
Amount of leucorrhoea not always proportioned to extent of disease, 372. 
Yellow leucorrhoea, when there is abrasion or ulceration, 373. How is the 
pain produced? 373. Bearing-down not always caused by displacements, 
373. Severity of suffering not commensurate with amount of disease, 374. 
Effects on the functions of the uterus, 374. Pain during menstruation, 
375. Kind of pain attendant upon uterine inflammation, 375. Cramping 
pain, 375. Effects of partial closure of the os uteri on menstruation, 375. 
Manner of flow modified by inflammation and congestion, 376. Duration of 
the flow, 376. Menorrhagia, 377. Menorrhagia frequent in endocervicitis, 
377. Amenorrhoea sometimes results, 377. Function of generation affected 
by it, 378. Sterility, 378. Abortion, 379. Conditions of the uterus in 
abortion, 379. Effect upon labor, 380. Effects upon the post-partum con- 
dition, 380. 

CHAPTER XVIII. 

PATHOLOGY OR HYSTEROPATHY. 

Mucous inflammation, 386. Seat of mucous inflammation, 387. Cavity of the 
body of the uterus, 387. Endocervicitis, 387. Endocervicitis with dimin- 
ished size, 388. Endocervicitis in virgins, 388. Endocervicitis in aged 
women, 388. External inflammation combined with internal in child-bearing 
women, 388. 

CHAPTER XIX. 

ETIOLOGY OF UTERINE DISEASE. 

CHAPTER XX. 

DIAGNOSIS OF UTERINE DISEASE. 

Characteristic signs of inflammation, 392. Diagnosis of endocervicitis, 392. 
Diagnosis of submucous inflammation, 393. Complication of mucous with 
submucous inflammation, 393. Size of the uterus ordinarily increased— 
exceptions, 393. Atrophy as the result of inflammation, 394. 

CHAPTER XXI. 



GENERAL TREATMENT OF UTERINE DISEASE. 

Main objects of general treatment, 397. General symptoms requiring special 
attention, 399. Nervous prostration, 399. Food, etc.; 401. Nervous 
excitability, 401. Anaemia, 403. Plethora, 404. Local congestions, 404. 
Constipation, 405. 



CONTESTS. XI 

CHAPTER XXII. 

SPECIAL TREATMENT. 

Baths, 415. Hip-bath, 416. Temperature of bath, 416. Shower-bath, 417. 
Sponge-bath, 417. Vaginal injections, irrigation, douches, 417. Accident 
in injection, 419. Should the}' be used in pregnancy ? 420. 

LOCAL TREATMENT, 422. Local alteratives, 426. Treatment of endo- 
metritis, 429. 

CHAPTER XXIII. 

LACERATIONS OF THE CERVIX UTERI. 

Causes, 435. The degree, locality and direction, 436. Effects of the laceration, 
436. Effects on the body of the uterus, 437. Complications, 437. Symp- 
toms, 438. Diagnosis, 438. Treatment, 438. Preparatory treatment, 439. 
The operation, 440. 

CHAPTER XXIV. 

OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND 

OPERATIONS. 

CHAPTER XXV. 

HYPERTROPHY OF THE CERVIX. 
Diagnosis, 446. Elongation of the supravaginal cervix, 447. 

CHAPTER XXVI. 

ACUTE PERIMETRITIS. 

Causes, 454. Symptoms, 454. Diagnosis, 457. Prognosis, 459. Local peri- 
tonitis, 460. Causes, 461. Symptoms, 461. Diagnosis, 463. Progno 
464. Treatment of perimetritis, 464. 






CHAPTER XXVII. 

CHRONIC PERIMETRITIS. 

Causes, 469. Varieties, 469. Symptoms and diagnosis, 471. Treatment, 473. 

CHAPTER XXVIII. 

DISPLACEMENTS OF THE VAGINA, BLADDER AND RECTUM. 

Urethrocele, cystocele, 479. Rectocele, 479. Symptoms, 479. Diagnosis, 480. 
Causes, 480. Treatment, 481. 



Xll 



CONTENTS. 



CHAPTER XXIX. 

DISPLACEMENTS OF THE UTERUS. 

What constitutes a displacement of the uterus, 486. Causes of uterine dis- 
placements, 486. Of descent and lapse, 486. Of prolapse and procidentia, 
487. Of displacements forward, backward, sideways, 487. Of versions, 
487. Of flexions, 489. Torsion or twisting, 493. Symptoms of uterine 
displacement, 494. Diagnosis of uterine displacements, 495. 

CHAPTER XXX. 

DISPLACEMENTS OF THE UTERUS CONTINUED. 

Treatment of uterine displacements — prophylactic, 498. Treatment of simple 
dislocations, upward, forward, and backward, 498. Descent or lapse, 500. 
Prolapse and procidentia, 501. Measures for diminishing the weight of the 
uterus, 501. Measures' to strengthen or elevate the pelvic roof supports, 
501. Cauterization, 504. Partial closure of the vagina, 504. Abdominal 
section, 505. Measures to supplement or restore the pelvic floor and perineal 
supports, 505. Hysterophores or pessaries, 505. Plastic operations upon 
the perineum or pelvic floor, 509. Choice of methods, 511. 

TREATMENT OF VERSIONS, 511. I. Anteversion, 511. Vaginal tarn- 
ponment, 512. Anteversion pessaries, 512. II. Retroversion, 514. In the 
acute and subacute stages, 514. Replacement, 514. Adhesions, 515. The 
vaginal pack, 516. Breaking up of adhesions, 516. Mechanical support, 
517. Pessaries acting in front of the cervix, or barrier pessaries, 518. 
Pessaries acting behind the cervix, or traction pessaries, 521. Pessaries 
acting both in front and behind the cervix, 522. Pessaries acting within the 
cervical canal, 523. 

CHAPTER XXXI. 

DISPLACEMENTS OF THE UTERUS — -CONTINUED. 

Operative procedures for retroversion, 525. To restore the uterus to its natural 
condition, 525. To restore the function of the uterine supports, 525. 
Shortening of the sacrouterine ligaments, 525. Shortening the round liga- 
ments, or the Alexander- Adams operation, 527. Indications, 528. Contra- 
indications, 528. The operation, 528. After-treatment, 531. Results of 
the operation— cases, 531. Dangers and difficulties, 534. Raising of the 
perineum or pelvic floor, 534. Operations of expedience, 535. Abdominal 
section for fixing the fundus forward, 535. Operation for holding or fixing 
the cervix backward, 535. Treatment of uterine flexions, 536. 



CHAPTER XXXII. 

DISPLACEMENTS OF THE UTERUS — CONTINUED. 

Retroversion and retroflexion of the uterus during pregnancy, 539. Causes, 539. 
Symptoms, 540. Diagnosis, 541. Termination, 541. Treatment, 541. 



CONTENTS. XI 11 

CHAPTER XXXIII. 

DISPLACEMENTS OF THE UTERUS — CONTINUED. 

Inversion of the uterus, 543. Symptoms, 544. Diagnosis, 545. Prognosis, 
546. Treatment, 546. The treatment of the chronic form, 549. 

CHAPTER XXXIV. 

DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

Causes, 558. Symptoms, 559. Prognosis, 559. Treatment, 559. Subinvolu- 
tion of the uterus, 562. Causes, 565. Frequency of its occurrence, 565. 
Symptoms and diagnosis, 566. Diagnosis, 566. Prognosis, 567. Treat- 
ment, 567. Hyperinvolution, 570. Causes, 570. Symptoms, 570. Diag- 
nosis, 571. 

CHAPTER XXXV. 

CANCER OF THE UTERUS. 

Symptoms, 574. Causes, 576. Diagnosis, 577. Prognosis, 578. Treatment, 
579. Palliation, 575. 

CHAPTER XXXVI. 

EPITHELIOMA, CANCROID, EPITHELIAL CANCER OF THE UTERUS. 
Diagnosis, 592. Prognosis, 593. Treatment, 594. 

CHAPTER XXXVII. 

SARCOMA. 

Symptoms, 607. Diagnosis, 608. Prognosis, 609. Treatment, 609. 
CHAPTER XXXVIII. 

• TUMORS OF THE UTERUS. 

Fibrous tumors, 610. Their nature, 612. Symptoms, 614. Diagnosis, 617. 
Prognosis, 619. 

CHAPTER XXXIX. 

FIBROUS TUMORS OF THE UTERUS — CONTINUED. 

Treatment, 624. Cases, 628. Summary of cases cured by absorption, 641. 
Modes of using ergot, 642. Different preparations, 644. Auxiliary treat- 
ment, 646. Corrective treatment, 646. Modus operandi, 647. Treatment 
by electricity, 654. Apostolus method, 655. Modes of action, 656. Dan- 
gers attending its use, 657. 



XIV 



CONTENTS. 



CHAPTER XL. 

SURGICAL TREATMENT. 

Removal of polypoid tumors, 658. Enucleation, 663. Laparotomy, 667. 
Laparo-hysterectomy, 668. Oophorectomy— Battey 's operation — spaying, 
673. Operation, 678. Physical and psychical results, 680. 

CHAPTER XLT. 

AFFECTIONS OF THE OVARIES. 

Congenital atrophy, 682. Hypertrophy, 682. Displacement, 682. Symptoms, 
684. The diagnosis, 684 Causes, 685. Effects, 685. Prognosis, 685. 
Treatment, 685. Acute ovaritis, 688. Treatment, 689. Chronic ovaritis — 
ovarian irritation, 689. Etiology, 690. Symptoms, 691. Diagnosis, 692. 
Prognosis, 693. Complications, 693. Treatment, 693. 

CHAPTER XLII. 

AFFECTIONS OF THE OVARIES CONTINUED. OVARIAN TUMORS. 

Anatomy, 695. Theories of their origin, 704. Modes of termination, 710. 
Causes, 712. Prognosis, 713. Diagnosis, 714. Remarks on diagnosis of 
ovarian tumors generally, 714. Physical examination, 715. Palpation and 
percussion, 716. Exploration, 719. " On the granular cell found in ovarian 
fluid," 720. Differential diagnosis, 723. 

CHAPTER XLIII. 

OVARIAN TUMORS — CONTINUED. 

Treatment, 730. Curative treatment, 736. Surgical treatment, 736. Injection 
of the sac, 740. Electrolysis, 745. Yaginal ovariotomy, 746. 



CHAPTER XLIV. 

ABDOMINAL OVARIOTOMY. 

General observations, 748. Treatment of the pedicle, 748. The ligature, 749. 
Drainage, 750. 

CHAPTER XLV. 

ABDOMINAL OVARIOTOMY CONTINUED. 

Preparation of the room, 761. Preparation, 761. Operation, 762. Second 
step, 764. Ovariotomy, 765. Third step, 769. 



CONTENTS. XV 

CHAPTER XLVI. 

OVARIOTOMY — CONTINUED. 
Accidents that may occur during the operation, 771. 

CHAPTER XLVII. 

OVARIOTOMY CONTINUED. 

After-treatment, 774. Treatment of the wound, 775. Attention to clothing, 
775. Vomiting, 776. Tympanites, 777. Hemorrhage, 778. Traumatic 
peritonitis, 779. Septicaemia, 781. Treatment, 782. Remarks, 783. 
Tumor of the broad ligament, or parovarian tumor, 784. Etiology, 785. 
Symptoms, 785. Diagnosis, 785. Prognosis, 786. Treatment, 786. 

CHAPTER XLVIII. 

FALLOPIAN TUBES. 

Salpingitis, 789. Symptoms, 790. Diagnosis, 791. Prognosis, 792. Treat- 
ment, 792. Surgical treatment, 795. Hemato-salpinx, 796. 



CHAPTER XLIX. 



Neuralgia of the coccyx, 798. Structure affected, 798. Symptoms, 798. Dia< 
nosis, 799. Prognosis, 799. Treatment, 799. 



INDEX OF ILLUSTRATIONS. 



1. Sagittal section of pelvic organs in the virgin, . . '. Byford 

2. Sagittal section of pelvic organs of child-bearing woman, 

3. Position of the uterus when the bladder is full, 

4. Schematic representation of the ligaments about the internal 

os uteri, 

5. Round ligament, " 

6. Schematic representation of round ligaments, 

7. Coronal section of the pelvis, Luschka 

8. Sagittal section of the pelvic connective tissue, . "Wm. A. Freund 

9. Horizontal section of pelvic connective tissue, . " " 

10. Position of the ovaries, Schultze 

11. Relation of ovary to posterior surface of broad ligament, 

Modified from Henle 

12. Positions of ovaries and Fallopian tubes, Byford 

13. Manner of insertion of the cervix uteri into the vagina, 

14. Horizontal section of pelvic floor near the pelvic outlet, . Henle 

15. Internal obturator muscle, .... Tarnier and Chantreuil 

16. Pelvic floor outlet, ........ Byford 

IT. Pubic attachments of the levatores ani et vaginae muscles, . Savage 

18. -Muscles of the pelvic floor, . . 

19. Horizontal section of pelvis, ....... 

20. Illustration of the action of abdominal pressure upon the 

uterus, Byford 

21. Voluntary contraction of the pelvic floor during straining and 

lifting, . " 

22. Perineal muscular system. (Schematic), .... 

23. Dissection of the muscles of the perineum and pelvic floor, . Savage 

24. Perineal fascia laid open, 

25. Pelvic floor and perineal fasciae, Byford 

26. Perineal triangles of virgin, 

27. Of married nullipar, ........ 

28. Of old woman, 

29. Of old maid before menopause, " 

30. Shape of relaxed perineal triangle, " 

31. Relations of muscles and fasciae to perineal body, . 

32. Folding of the perineal bod} T . in normal labor, 

33. Flattening of the perineal body in labor, .... 

B 



XV111 



IXDEX OF ILLUSTRATIONS. 



Fig. 34. 

35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 

46. 

47. 

48. 

49. 

50. 
51. 



54. 
55. 

56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 

64. 

65. 
66. 

67. 
68. 
69. 
70. 
71. 
79 



Muscular fibres of rectum, 

Distended rectum, 

Relation of the ureters to the bladder and uterus, . 
Distribution of the ovarian, uterine and vaginal arteries, 
Operating chair, ......... 

Byford's operating table, 

Position for Sims's speculum, 

Virgin uterus and vagina, 

Uterus of the child-bearing woman, . 

Senile uterus and vagina, ... . . . . 

Digital examination in the dorsal position, . . . . 

Bimanual palpation of the uterus from the posterior vaginal 

wall, 

Bimanual palpation of the uterus through the anterior vaginal 

fornix, 

Uterus artificially turned back against the hollow of the 

sacrum, for palpation of the posterior wall, 
Positions of ovaries as seen from the pelvic brim, Modified from 
Artificial tension of the round ligaments, using the sacro-uterine 

attachment as a fulcrum, 

Position of the uterus produced by contraction of the round 

ligaments, 

Position of the ureters. (Schematic), 

Uterine torsion produced by contraction of the sacro-uterine 

ligament of one side, ... . . Modified from 

Position of uterus produced by contraction of the sacro-uterine 

ligaments, ........ 

Method of introducing the finger into the rectum, . 
Bimanual examination of the posterior surface of the uterus 

and the posterior pelvic spaces from the rectum, 
Recto-vaginal grip of the retroverted uterus, . 
Bimanual circumdigitation from the rectum and vagina, . 
Palpation of the uretral orifices, . ... 

Grasping the coccyx, 

Anterior surface of the sacrum, ..... 

Vaginal entrance of the virgin, 

Vaginal entrance of the married nullipar, 

Vaginal entrance of the married nullipar, with contracted or 

short levator ani, . 
Vaginal entrance with greatly relaxed or destroyed levator 

vaginae, 

Same as above, except that the levator ani is short, 

Shape of vulval orifice, 

Same, of married nullipar, ...... 

Same, of child-bearing woman, 

Simpson's sound, 

Sims's sound, ......... 

Jeuks's uterine probe, 

Fitch's measuring sound, 

Introduction of the uterine sound, 



Byford 

u 

Luschka 
Hyrtl 

Sargent 

Byford 



Schultze 
Byford 

i ; 

Schultze 
Byford 



Winckel 

Byford 

Gray 

Byford 



Truax 



Byford 



INDEX OF ILLUSTRATIONS. 



XIX 



74. 
75. 
76. 

77. 
78. 

79. 
80. 
81. 

82. 
83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114 
115 
116. 
117, 
118, 
119 
120, 
121 
122 



Uysterometer, 

Method of applying hysterometer, 

Higby's speculum, 

Nott's speculum, . 

Nelson's speculum, closed, 

Nelson's speculum, open, 

Nelson's tenaculum, 

Double tenaculum forceps, 

Tenaculum forceps, 

Speculum introduced, . 

Dressing forceps, . 

Sims' s speculum, . 

Sims' s depressor, . 

Tenacula, 

Nott's tenaculum forceps, 

Simon's speculum, 

Simon's retractors, 

Lever for dilating the vagina from the side. 

Action of the instruments in Sims's method of examinin 

uterus, 
Sponge tent, . 
Laminaria tent, 
Tupelo dilators (hollow), 

Compressed slippery-elm tents, straight and curve 
Compressed slippery-elm tent, hollow, 
Tent mounted on tent-holder, 
Molesworth's dilator, 
Hanks' dilators, 
Probe curette, 
Thomas's wire curette, . 
By ford's finger curette, . 
Sims's sigmoid catheter, 
G-oodman-Skene's self- retaining catheter, 
Skene's urethral endoscope, 
Simon's urethral catheter, 
Elephantiasis of the labia, 
Cancer of the labia, 

Folding of the perineal body in normal labor, 
Flattening of the perineal body due to rigidity, 
Diagonal flap laceration of perineum, left side, 



1 



Triangular lacerations of the perineum, 

Diagonal lacerations of the perineum, . 
Diagonal bilateral laceration with vulval extension 
Same, with extension into the rectum, . 
Double diagonal and transverse laceration, 
Same, with both vulval extension and transverse, 
Degrees of median laceration through perineal raphe, 
Degrees of extension of diagonal laceration through 
raphe, 



Byford 

Truax 

Sargent 



Tiemann 

u 

Byford 
Truax 



Sargent 



the 



Byford 
Sargent 

Tiemann 

Truax 
cc 

Sargent 

u 

Truax 



Tiemann 
Winckel 
Scanzoni 
McClintock 
Byford 



the 



XX 



INDEX OF ILLUSTRATIONS. 



Fig. 123. Deformity produced by the transverse or deep double diagonal 

laceration, 

" 124. Incisions to be made in perineal tenotomy, . 

" 125. Perineal tenetome, double, 

" 126. Deep suture entered near edge of wound, 
" 127. Deep suture entered at a distance from edge, 
" 128. Edges of wound pared to prevent compression, 

" 129. Flap stitch, 

" 130. Triangular denudation of perineum. (Schematic), 

" 131. Modified triangular denudation of perineum, 

" 132. Appearance of the modified triangular denudation between 

separated labia, . 

Bilateral denudation with stitches passed, . 

Same, with vaginal stitches tied, ..... 
Martin's modification of the bilateral denudation, .' 
Crescentic denudation with vaginal stitches passed, 

Same, with vaginal stitches tied, 

Crescentic, modified, 



133. 
134. 
135. 
136. 
137. 
138. 
139. 
140. 
141. 
142. 
143. 
144. 
145. 
146. 
147. 
148. 

149. 
150, 

154. 

155. 

156. 

157. 
158. 
1 59. 
160. 
161. 
162. 
163 
165 

166. 
167, 
168. 
169. 



Byford 

cc 

Truax 
Byford 



Zweifel 
Byford 

cc 

Martin 
Byford 



r Star denudations, 

Lines of incision in triangular flap operation, . Hart and Barbour 
Same, with flaps raised and sutures passed, . . " 

Denudation, as made by Bishoff, Byford 

Unilateral flap denudation, . • 

Hegar's triangular denudation, ...... Hegar 

Freund's bilateral denudation, Kuestner 

Triangular flap operation, applied to lacerations extending 

into the rectum, Hart and Barbour 

Same, with flaps raised and stitches passed, . . " 
151, 152 and 153. Unilateral flap operations applied to lacera- 
tions extending into the rectum, ..... Byford 

Emmet's method of passing sutures in lacerations deep into 

the recto- vaginal septum, ..... . Emmet 

Splitting of perineum and flap stitches passed after the 

manner of Lawson Tait, Zweifel 

Perineum scissors, Truax 

Langenbeck serres-fine for compressing arteries, . . . " 

Silver sutures, properly bent, Byford 

Silver sutures twisted without being properly bent, . . " 
Method of securing twisted ends of silver sutures, . . Emmet 

Quilled sutures, tied, Zweifel 

Skene's double perforated catheter, Truax 

and 1 64. Urinary fistulae, Byford 

Tenaculum, with which to hold the edge of fistula while being 

pared, Sargent 

Curved scissors, for paring edge of fistula, . . . . " 

Wire adjuster, . " 

Speculum, for dilating vagina, " 

!•"< nveps, for twisting the wires, " 



INDEX OF ILLUSTRATIONS. 



XXI 



Fig. 170. The catheter, 

" 171. Needle forceps, 

" 172. Sponge-holder. The instruments are represented half-size, 

" 173. Method of paring the edges of a urinary fistula, 

" 174. Method of passing the needle, 

11 175. Method of using the tenaculum, etc., . 

" 176. The fistula, with edge pared and sutures placed, 

" 177. Wire adjuster, 

" 178. Twisting the wire sutures, .... 

" 179. Removing the sutures, 

' l 180 to 185. Simon's method of operating upon urinary fistuli 

" 186 and 187. Kolpoklesis, 

" 188. Bozeman's apparatus, ..... 

" 189. Bozeman's button, . . . 

" 190. Same, with sutures tied, .... 

" 191. Strong retroflection, favoring gravitation to the fundus 

" 192. Retroflexed uterus, with fundus raised by a pessary, 

" 193. Sims's method of dividing the cervix, . 

" 194. Emmet's knife, for dividing the cervix, . 

" 195. Division of the flexed cervix, 

" 196. Peaslee's metrotome, 

" 197 to 200. Uterine cavity after different methods of di\ 
" 20J. Gooclell's uterine dilator, .... 
" 202. Fountain syringe and douche pan, 

" 203. Ointment syringe, 

" 204. Uterine scarificator, ..... 
" 205. Dr. Buttle's uterine scarificator and leech, . 

" 206. Slippery-elm tent, 

' 207. Slippery-elm tent, introduced, 

Same introduced in case of anteflexion, 

The cervix, with threads passed, . 

Lacerated cervix, after denudations, 

Byford's uterine scissors, .... 

Mode of passing the sutures, 

213. The sutures properly placed and twisted, 

214, 215. Hypertrophy of the cervix uteri, . 
216. Supravaginal elongation of the cervix, . 

Amputation of the cervix by Sims's method, 
Same, with sutures tied, .... 
Amputation of cervix, by Simon's method, . 
Stoltz's denudation for cystocele, . 

221. Pathological changes in location of the uterus. Dislocations 

222. Pathological anteflexion caused by shortening of the sacro 
uterine ligaments, 

Anteflexion, produced by a contraction of the round ligaments 

Puerile anteflexion, 

Anteflexion, with retrolocation and retroversion 
Extreme retroflexion of the uterus, 
Natural position of the body, 



208. 
209. 
210. 
211. 
212. 



217. 
218. 
219. 
220. 



223. 
224. 
225. 
226. 

227. 



Sargent 



Byford 



228. Unnatural, or stooping position of the body, 



Simon 
Bozeman 

u 

Byford 

Sims 
Emmet 

Sims 
Peaslee 

Truax 



Sargent 

Truax 

Byford 



Emmet 
Sargent 
Byford 



Sims 

Simon 
Munde 
Byford 

Schultze 
Byford 

Schultze 
Byford 



xxu 



INDEX OF ILLUSTRATIONS. 



Fig. 229. Anteversion and retroversion, 

" 230. Anteflexion and retroflexion, 

" 231. Soft rubber inflated pessaries, 

" 232. Peaslee's elastic ring, 

" 233. The Sims-Emmet denudation for cystocele and procidentia, 
" 234. Lateral denudation in the urethral fossae and anterior vagin 

sulci, 

" 235. Denudation for raising and strengthening the whole vesico 

vaginal septum, .... 

" 236. Suture passed so as to catch up the bottom of the wound, 

" 237. Same, united, 

" 238. Suture passed and tied in the usual manner 

" 239. Fitch supporter, 

" 240. Silk elastic belt, 

" 241. Schultze's sleigh pessary, 

" 242. Zwank's pessary, ..... 

" 243. Mcintosh uterine supporter, 

" 244. Mcintosh supporter applied, 

" 245. Thomas's modified Cutter pessary, 

" 246. Scott's pessary 

" 247. Pessary, with tapes for attachment to a belt, 
" 248. Outlines of denudation for procidentia, . 
" 249. Denudation for procidentia, after Fritsch, 
" 250. Denudation for procidentia, after Reamy, 
" 251. Grehrung's pessary for anteversion, 
" 252. Hewitt's anteversion pessary, 
1 253. Thomas's anteversion pessary, 
" 254. Byford's pessary, with the neck elevated, for the relief of 

anteversion, 

" 255. Anteversion pessary, acting by lidding the lower end of tl 

cervix forward, .... 

" 256. Byford's retroversion pessarj 7 , 
' 257. Byford's retroversion and prolapse pessary 
' 258. Byford's retroversion pessary in place, . 
" 259. The Albert Smith retroversion pessary, 
" 260. Hodge's closed lever pessary, 
" 261. Hewitt's cradle pessary, 
" 262. Thomas's retroflexion pessary, 
" 263. Fowler's pessary, ..... 
• 264. H. Marion Sims's retroversion stem pessary, 
' 265. Needle mounted upon needle-holder, for introducing sutures 

into the sacro-uterine ligaments, 
' 266. Byford's probe-pointed scissors for cutting fascia, 

" 267. Byford's broad hook, 

' 268. Curves of posterior vaginal walls, after a poorly performed 

perineorrhaphy, .... 
" 269. Jackson's intra-uterine stem, 
' 270. Thomas's bulb retroflexion pessary, elastic, 
" 271, 272. White's repositor, . 
k 273. Reduction of inversion by the elastic bag, 



Schultze 

Byford 

Truax 

Byford 



Tiemann 

Truax 
Sargent 



Truax 
Sargent 
Byford 
Winckel 
Fritsch 
Beamy 
Sargent 
Tiemann 



Byford 



Truax 

Byford 

Sargent 

Truax 

Reynders 

Truax 

Ford 

Byford 

Truax 



Byford 

Truax 

Sargent 

Tiemann 

Byford 



INDEX OF ILLUSTRATIONS. 



XX111 



Fig. 274. Sharp curette, 

275. Simon's curette, . 

276. Epithelioma of uterus, 

277. Epithelioma of the cervix, 

278. Fungus growing from the cervix, 

279. Structure of epithelioma, 

280. Dr. Paquelin's thermocautery, 

281. Byrne's cautery battery, 

282. Byrne's cautery ecraseur, 

283. Byrne's cautery electrodes, . 

284. Structure of sarcoma, . 

285. Origin of fibroid tumors, 

286. Fibroid polypus, . 

287. Submucus fibroid tumor, 

288. Sub-peritoneal fibroid tumor, 

289. Intramural fibroid tumor, 

290. Chassaignac's ecraseur, 

291. Small vulsellum forceps, 

292. Medium-sized vulsellum forceps, 

293. Large vulsellum forceps, 

294. Sims's enucleator, 

295. Sims's guarded hook, to aid in drawing 

296. Thomas's serrated spoon, 

297. Aspirator, 

298. Microscopic examination of fluid fi 

299. Fitch's trocar, 

300. Trocar, . 

301. Nelaton's forceps, . 

302. Sponge holder, 

303. 304. Rubber coil, . 
305, 306. Enucleation of cysts of the broad ligament 



om o\ 



Shepard and Dudle}' 
. Byford 



Cornil and Ranvier 

Codman and Shurtleff 

Shepard and Dudley 



Cornil and Ranvier 
Byford 



Sargent 
Truax 

Sargent 
Tiemann 



the tumor, 



Codman and 
arian tumors 



Shurtleff 

Atlee 

Sargent 



Truax 



Byford 



DISEASES AND ACCIDENTS 



INCIDENT TO WOMEN 



CHAPTER I. 



PKACTICAL OBSEKVATIONS UPON THE ANATOMY AND PHYSIOLOGY 
OF THE FEMALE PELVIC OKGANS. 



The uterus is normally situated in the median line of the body, 
between the bladder and rectum, just below the pelvic brim (Figs. 1 



Fig. 1. 




Sagittal Section of Female Pdlvic Organs in the Virgin { l /Q. 
U, uterus, B, bladder; i?, rectum ; pt, perineal triangle; pf, perineal floor; pfe, perineal floor 
edge ; S, symphysis pubis ; P. promontory of sacrum ; ppr, plane of pelvic roof; prp, pelvic roof 
projection ; ss, superior strait ; ass, axis of superior strait. 

and 2). It is often found so twisted upon its long axis as to bring the 
left side a little farther forward than the right, and the cervix some- 

2 



18 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

what to the left of the median position. It has three systems of sup- 
ports : the pelvic roof, or the sustaining ; the pelvic floor, or retaining ; 
and the perineum, or supplementary support. 

I. Pelvic Roof. 

The pelvic roof is formed by the expansion and reduplication of 
the peritoneum upon and between the pelvic viscera, with whose 

Fig. 2. 




Sagittal Section of Pelvic Organs of Child-bearing Woman {\Q. 
vp, vaginal promontory. (See Fig. 1 for further explanation.) 



walls, and the circumposed connective, muscular, vascular, and 
glandular tissues, it unites to form an exceedingly elastic and per- 
fectly adequate uterine support, These duplicatures or folds are 
called the pubo-uterine, or pubo-vesico-uterine, in front, stretching 
from the pubes to the anterior surface of the uterus: the sacrouterine 
or sacro-recto-uterine (folds of Douglas, or posterior suspensory liga- 
ments) behind, passing from the posterior walls of the uterus and 
vagina to the sacrum ; and the broad ligaments (ligamenta lata, alar 
ligaments) on the sides passing across the anterior and posterior 



MUSCULATURE OF THE PELVIC ROOF. 



19 



uterine surfaces to the sacroiliac synchondroses (Fig. 4) ; and the 
round ligaments, reaching in a curve from the sides of the uterus 
near the fundus forward to and through the inguinal canals. 

Musculature of the Pelvic Roof. 

The round ligaments (Figs. 5 and 6) are muscular cords about the 
size of a large goose-quill, given of! from the external muscular coat 




Position of the Uterus when the Bladder is full Q/Q. 
ppr, plane of pelvic roof ; prp, pelvic roof projection ; ss, superior strait : 
strait. 



axis of superior 



of the uterus under the Fallopian tubes. They pass a short distance 
between the layers of the broad ligaments, emerge from their anterior 
surfaces to enter the inguinal canals, where they receive a connective 
tissue sheath. A portion of the muscular fibres, with others from the 
sheath, form an intimate attachment to the external pillar of the 
external ring, and a looser attachment to the internal pillar, while the 
remainder pass on to the pubic bone. The connective tissue sheath 
affords an elastic attachment of the ligaments throughout the canals. 
They pursue a curved course, but are somewhat straightened and put 
slightly upon the stretch, when the fundus uteri and the broad liga- 



20 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

ments, or either, are lifted upwards and backwards by the filling of 
the bladder, or by improperly applied abdominal or other pressure. 
Unless misplacing forces have acted too long they will promptly bring 
the fundus and, to a certain extent, the broad ligaments back into 
normal unconstrained relationship with their surroundings. 

Muscular fibres can also be traced from the bladder and uterus into 
the pubo-vesico-uterine connective tissue, aiding in drawing and hold- 
ing the cervix sufficiently forward. The muscular walls of the base 

Fin. 4. 




Schematic representation of the Ligaments abouc the Internal Os Uteri, at the plane of the pelvic 
roof. Drawn upon Schultze's diagram of the female pelvis, one-third the natural size.* 
E P M., edge of psoas muscle; B B L., base of broad lig.; I O., int. os.; S U L., sacro-uterine lig.; 
S P P., sacral peritoneal pouch. 

of the bladder, and particularly the anterior wall of the vagina, as 
long as the intervening connective tissue is firm, add materially to 
the strength of these anterior supports. Quite an abundance of mus- 
cular tissue also extends from the posterior cervical and vaginal walls 
under the sacro-uterine folds to the rectum, to the periosteum of the 
second sacral vertebra, and to the neighboring tissues. Thus strength- 
ened these folds reach in a semicircle partly around the rectum, and 
suspend the cervix almost directly underneath the second sacral 
vertebra, in such manner that the weight of the corpus with the trac- 
tion of the round ligaments acts to keep the fundus over the bladder. 
Some of these posterior fibres, with others from the uterus and vagina, 
also run into the broad ligaments, and strengthen them in their lateral 
traction upon the cervix and vaginal walls. Sometimes they form 



* Schultze's outline figures of the pelvis are freely copied in many of the schematic 
drawings in this book as being the best and most available for the purpose. 



MUSCULATURE OF THE PELVIC ROOF. 



21 



two bands : one passing outward in front of the vessels and nerves to 
the anterior peritoneal fold of the ligament, and the other back of the 




Round Ligament passing under the anterior layer of the Broad Ligament. 
P.L., round ligament; LP., infundibulo-pelvic ligament; F.T., Fallopian tube; U, uterus; 
O, ovary upon opposite side ; M.S., meso-salpinx. 

vessels and nerves to the posterior fold (William A. Freund). The 
upper portions of the broad ligaments, held forward by the round 

Fig. 6. 



hrc 




Schematic Representation of Round Ligaments Q/£). 
a, fundus uteri behind symphysis pubis; b, fundus uteri against the sacrum ; c, fundus uteri 
when the bladder is full ; ov l , ovary belonging to b ; <n«, ovary belongingto a, with relaxed round 
ligament; go 3 , ovary belonging to a, with tight round ligament; arc,brc, ere, round ligament 
belonging to a, b, and c, represented as somewhat contracted, or tense ; ar, br, cr. round ligament 
relaxed. 



22 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

ligaments, present their posterior surfaces to the superincumbent 
abdominal viscera, and thus also tend to keep the ovaries and the 
fundus uteri forward. It is not improbable that, being thus elastic 
and attached to the sides of the pelvis a little behind the transverse 
central diameter (farther back on the right than left side), they are 
rendered sufficiently tense, when the bladder is empty, to help hold- 
the fundus up from the vesico-vaginal septum. 



Peritoneal Covering of the Pelvic Roof. 

Behind the uterus the peritoneum dips below the vaginal junction 
from a few lines to an inch or more (Fig. 1), forming the recto-uterine 
pouch (cul-de-sac of Douglas), and is reflected back upon the rectum, 
which it covers from this level upward. Over the posterior surface 

Fig. 7. 




Diagram of Coronal Section of the Pelvis (Luschka). 
a, peritoneal cavity ; b, subperitoneal cavity ; c, ischio-rectal fossa ; d, uterus. 

and fundus of the uterus the peritoneum is firmly attached ; on the 
anterior surface it becomes less firmly adherent as it passes down, 
and in the neighborhood of the internal os where it is reflected over 
the bladder, forming a vesico-uterine pouch, permits itself during 
filling of that viscus, during pregnancy, and in some pathological 
conditions, to be stripped from both the uterine and vesical surfaces 



PELVIC CONNECTIVE TISSUE. 



23 



for quite a distance. Between the bladder and anterior abdominal 
wall the peritoneum does not reach down quite as low as the upper, 
edge of the symphysis pubis, is loosely attached here also, and may 
be stripped from its lower connections the same as between the bladder 
and uterus. Under favoring conditions it allows the bladder and 
vagina to be approached extra-peritoneally through the abdominal 
walls. At the time of parturition the peritoneum is said to be entirely 
separated from the bladder (Hart). Behind the broad ligaments — in 
the sacral pouches — the peritoneal cavity reaches down to about the 
level of the internal os ; in front of them in the para- vesical pouches 
it does not dip quite so low. 

Pelvic Connective Tissue. 
As connective or fibrous tissue exists everywhere in the body, form- 
ing one continuous network, penetrating and surrounding, strength- 




Sagittal Section of Pelvis through the Connective Tissue Chamber, through Left Broad Liga- 
ment near the Uterus, cutting off a corner of the Bladder and of the Left Vaginal Fornix (W. A. 
Freund). 

ening and supporting the various structures, it naturally plays an 
important part in the pathology of the pelvic organs. It exists in 



24 AX ATOMY AXD PHYSIOLOGY OF FEMALE PELYIC ORGANS. 

small quantities everywhere under the peritoneum ; in larger quanti- 
ties between the bladder and the symphysis in the median line, along 
the vesicovaginal septum, between the bladder and uterus, and be- 
tween the layers of the broad ligaments ; while under the sacro-uterine 



ZncUctcrat Vertebra, 



Ccnnectt^e Tissue 
-witHoict Tax. 
Consic£llve Tissue 
containing Tut 

XtcodfyesseCs 




£7acUler 



Horizontal Section of Pelvis through the Second Sacral Vertebra and Pubis (W. A. Freund). 



and broad ligaments on either side it is so abundant as to form a large 
connective-tissue chamber (Figs. 7, 8, 9). 

These chambers are bounded above by the reflected peritoneal folds 
of the broad ligaments over the para-vesical and sacral pouches, below 
by the levatores ani and coccygei muscles, internally by the rectum, 
vagina, cervix and base of the bladder, posteriorly by the sacrum, an- 
teriorly by the pubes and superior attachments of the levator ani, and 



THE OVARIES AND THEIR RELATIONS. 25 

laterally by the iliac bones and upper edge of the obturator interims. 
More properly speaking, there is only one such subperitoneal connec- 
tive tissue chamber which extends across the vesico-vaginal septum 
and contains the cervix, vagina, rectum and base of the bladder in its 
centre. Fig. 8 represents a sagittal section on the left side of the 
uterus ; Fig. 9 represents half of a horizontal section through the 
second sacral vertebra and pubes. The extent of the chamber is 
shown, although the shape and relationship of parts is not exactly 
such in the living body. 

Innumerable bloodvessels, nerves and lymphatics traverse this tis- 
sue in every direction, to and from the different organs and structures, 
and depend upon its integrity for the healthy performance of their 
functions. 

About the cervix the connective tissue contains no fat but receives 
muscular fibres from the uterus, rectum and bladder, and is, there- 
fore, unusually elastic and displaceable, allowing the cervix to be 
moved in every direction without violence. This is the parametrium 
of Virchow. Around the pelvic walls the connective tissue contains 
an abundance of fat which gradually diminishes in quantity toward 
the centre. In front and at the sides it disappears abruptly at the 
ureters. The fat adds to the firmness of the tissue, and, hence, to its 
supporting and resisting power; but it diminishes its elasticity and 
thus increases its liability to contusion and laceration from great 
violence. 

About the pelvic viscera the connective tissue, receiving fibres from 
them, becomes more dense so as to form a sort of sheath (hohlcylinder 
of W. A. Freund) or external fibrous coat ; about the muscles it is 
condensed into firm fascia and tendon, and supports muscular con- 
traction. 

In fleshy people the abundance of fat renders the whole connective 
tissue stronger and less elastic without strengthening the fasciae ; while 
in people of great muscular development the fasciae become firm, and 
the connective tissue, although less resistant and rigid than when over- 
filled with fat, is more powerfully retractile and better capable of normal 
and vigorous function. In the young adult female there is usually an 
abundance of fat in the tissue, combined with great elasticity of fascia, 
producing a condition of strength and retractility ; in the middle-aged 
nullipara there is usually an increase of fat and a progressive harden- 
ing of the fascia, producing a condition of great strength and rigidity ; 
in the aged there is an absorption of fat and a shrinking of the fascia, 
diminishing the strength but increasing the rigidity (or brittleness) of 
the tissue. 

The Ovaries and their Relations. 

The ovaries lie on the posterior surfaces of the broad ligaments with 
their long axes inclined from their lateral attachment to the psoas 



26 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

fasciae, forwards and inwards towards the symphysis. Schultze's 
schematic representation (Fig. 10) shows the position in which I have 
frequently found them. Yet I have also found them sagging down 
or back & little, or swinging a trifle around their external attachments 
even in cases of normally placed uteri, and, therefore, think that their 



Fig. 10. 




Position of the Ovaries (after Sclmltze) 0^). 
a. fundus of uterus behind pubes ; b, fundus when the bladder is full ; c, sacrum ; ap, anterior 
superior spine of ileum ; ps, edge of psoas muscle ; ip, infundibulo-pelvic ligament ; ov 1 , nor- 
mally placed ovary ; ov-, ovary drawn back into the hollow of the sacrum by displaced fundus 
uteri ; ov 3 , ovary drawn back beside cervix by the replaced fundus ; ot 4 , ovary pressed or held 
forward when fundus is back ; ft, Fallopian tube ; ol, ovarian ligament. 

position is within physiological limits a slightly variable one, and is 
affected by abdominal pressure, and by temporary alterations in the 
conditions and relations of the abdominal and pelvic viscera. Fig. 11 
represents the broad ligament and its contents, modified from Henle. 
Schultze teaches that the ovarian ligaments, which pass from the 
anterior-inner end of the ovaries to the uterus just below the Fallopian 
tubes, and are four inches across (including the uterus), do not change 
the position of the ovaries during lifting of the fundus by the filling of 
the bladder (Fig. 10). But when the fundus leans back against the 
sacrum, the anterior inner ends of the ovaries are drawn to the back 
part of the pelvis ; they pass from ov 1 to ov 2 . The infundibulo-pelvic 
ligaments (Fig. 11) or outer upper end of the broad ligaments are 
folds of peritoneum extending from the Fallopian tubes and ovaries to 
the pelvic wall, and contain a little fibrous tissue, which passes, some- 
times in visible quantities, upward upon the outer surface of the peri- 
toneum. They limit the motion of the peripheral end of the ovary 
and the fimbriated extremity of the tubes to a small area at the sides 
e pelvis ^Figs. 10 and 12). Ov z , Fig. 10, indicates the position of 



URETERS. 



2? 



the ovaries as dragged back by the replaced fundus before the abdomi- 
nal pressure has had an opportunity to press the broad ligaments for- 
ward. On account of the looseness of attachment of the peritoneum 
to the psoas and iliac muscles, the infundibulo-pelvic ligament may 
be drawn out so as to allow the ovary to get away from the pelvic 
wall even into the recto-uterine pouch. (See Fig. 48 ov*.)* 

The Fallopian tube, being too long for the space it occupies, pursues 
an undulating course and floats loosety at the pelvic brim, over the 

Fig. 11. 




Relation of Ovary to Posterior Surface of Broad Ligament (modified from Henle). 
1, infundibulo-pelvic ligament. 

meso-salpinx — that part of the broad ligament between it and the 
ovary and ligament behind, and the uterine end of the round liga- 
ment in front (Figs. 5, 8 and 11). 

Thus while the lower or cervical portions of the broad ligaments 
are somewhat resilient and act the part of true supports to the cer- 
vical end of the uterus, their upper portions are somewhat volumi- 
nous and movable and do not act efficiently until the fundus falls far 
forward or backward. 

Ureters. 

The ureters enter the base of the bladder at the basal angles of the 
trigone, an inch apart, and are connected by a continuation of their 
own structure (Garriguez) forming the inter-uretric ligament (see Fig. 
36). They pass (as traced from the bladder toward the kidneys) 



See " How to Palpate the Ovaries," chap. II., p. 59. 



28 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

divergingly backward for about three-fourths of an inch between the 
coats of the bladder to emerge from one and a half to two inches apart 
and from one-half to three-fourths of an inch in front of the cervix 
(Savage). From their points of emergence they pass in slight curves 
backward, outward and upward, under and behind the bases of the 
broad ligaments, near the spina ischia. They then turn sharply up- 
ward, behind the external attachments of the ligaments and external 
to the internal iliac arteries, pass up behind the lateral sacral perito- 

FlG. 12. 




Positions of Ovaries and Fallopian Tubes when the Fundus a is behind the Pubes ; and b 
when against the Sacrum (%). 
ov l , ovary and Fallopian tube held normally forward with a ; or 3 , ovary and tube pressed back 



while a is held forward ; or 2 , ovary and tube carried back with o; 
forward while 6, to which they belong, is back against the sacrum. 



ovarv and tube held 



neal pouches, across the anterior surface of the external iliac and 
behind the sigmoid flexure, or ileum, up over the psoas muscle, be- 
side the main bloodvessels, to the kidney. The ureters thus run 
through the subperitoneal connective-tissue chamber and mark the 
boundary of the fat containing tissue externally, and that without fat 
internally (W. A. Freund). They pass under and behind, but not 
into the peritoneal cavity, and are practically inseparable from the 
outside surface of the peritoneum behind the broad ligaments, and 
the dense connective tissue under them. 



Vagina. 

The vagina is attached posteriorly to the cervix, the sacro-uterine 
ligaments, the rectum, and by the rectovesical fascia to the levator 
ani muscles ; superiorly to the anterior portion of the cervix, the bases 
of the broad ligaments and to the pubo-uterine tissues; and anteriorly 
and inferiorly by the recto-vesical fascia to the pubes, and to the 



VAGINA. 



29 



levator vaginae muscle, which passes around the vaginal introitus like 
a sling or sphincter (Fig. 13) and mingles with the longitudinal mus- 
cular fibres of the external vaginal coat. Behind the symphysis on 
either side of the urethra the vaginal wall is drawn up behind the 
posterior surfaces of the pubes and the pelvic fascia, forming, to the 
touch, an oval fossa on either side, which we will call the urethral fossa?. 
The urethra, passing as a ridge down between these urethral fossae 



Fig. 13. 



\PPr 




Manner of insertion of the Cervix Uteri into the Vagina, showing the relation of the Vagina to 
the Pelvic Roof (Schematic— y 2 ). 
ppr, plane of the pelvic floor ; su, sacro-uterine ligament ; Iv, levator vaginee fibres, passing up 
to posterior surface of pubes ; pu, connective-tissue attachment of anterior vaginal wall to pubo- 
uterine system ; ass, axis of the superior strait of pelvis ; a 6 c, division of cervix into the infra- 
vaginal portion (a), the intermediate (&) and the supra-vaginal portion (c) (after Schroeder). 

and under the pubic arch, leaves a depression or notch on either side, 
the urethral notches, leading from the arch back into the fossa}. (See 
Fig. 14 UN, and Fig. 16.) Farther back the anterior wall becomes flat 
and forms, at the junction with the lateral walls, the anterior vaginal 
sulci or grooves, which lead from the urethral fossa? back to the 
lateral fornices. 

The vagina is thus suspended from the pelvic roof in the subperito- 
neal or pelvic connective tissue chamber. It may be likened to a col- 
lapsed cylinder into whose upper side the cervix is inserted at a right 
or acute angle with its longitudinal diameter, and near its upper ex- 
tremity. Fig. 14 (from Henle) shows the manner of collapse at the 
vaginal entrance in the cadaver. In the living subject the contraction 
of the levator vaginae would tend to shorten both the rectal and vaginal 
slits, and thus slightly differ from the figure. The posterior vaginal 
wall above the introitus is from a half-inch to an inch and a half above 
the pelvic floor in the median line, is applied to the flat anterior wall 
by the action of the levator ani muscles, the rectum, atmospheric 



30 AX ATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 



pressure and elasticity of the surrounding tissue. The rectum in pass- 
ing under the vagina forms a broad longitudinal ridge a little to the left 
of a median position. On either side of this ridge the mucous mem- 
brane of the introitus vaginas forms a notch, which may be called the 



Fig. 14. 




Horizontal Section of Pelvic Floor near the Pelvic outlet (Henle). 
Ua, Urethra ; Va, vagina ; E, rectum ; UN, urethral notches ; RN, rectal notches. 

rectal notches, the right one of which is deeper and broader than the 
left (Figs. 14 and 16). These rectal notches also lead into posterior 
vaginal grooves or sulci corresponding to those in the anterior walls. 
The elevation or projection of the lower end of the posterior wall where 
it is held up by the levator vaginae and rectum forms the recto-vaginal 
promontory of Prof. T. G. Thomas. The vagina passes backwards at an 
angle of from 30 to 45 degrees with the horizon, according to the ten- 
sion of the muscles and fasciae about the vaginal entrance and uterine 
ligaments.* In the child-bearing woman the posterior vaginal wall 

* A measurement of D. B. Hart's figure upon which he bases his statement that the 
vagina passes back at an angle of 60° with the horizon, will show that the uterus and 
vagina are both reduced £ in length and the perineum prolapsed and distorted, either 
by spirit hardening or other post-mortem changes, and. cannot stand for the position of 
the parts in life. A normal uterus 3 inches long placed with the vagina at an angle 
of 60° would lift the os two inches from the coccyx, and project the anteverted fundus 
above the pelvic brim upon, instead of behind, the symphysis pubis. The difference 
in the inclination of the vagina in the living and the dead would seem to be caused 
largely by the greater sagging of the lower end of the vagina. The recto-vaginal pro- 
montory is depressed by relaxation of tissue, and the urethra, with its bed of connec- 
tive tissue, being unsupported, comes clown with the anterior vaginal wall. 



RELATION OF UTERUS TO BLADDER. 31 

often lies on the rectum or pelvic floor, especially when depressed by 
a heavy uterus, and partially unfolded by the examining finger. The 
vagina, by lining or cementing together the pelvic roof, also materially 
adds to the strength of the suspensory uterine supports. The uterus 
not unfrequently receives some support by resting upon a contracted 
posterior vaginal wall, but hardly ever rests with the whole weight 
upon the pelvic floor, unless it, or its superior supports, have lost their 
healthy and natural condition and relationship. 

Plane of the Pelvic Roof. 

The chief plane of the pelvic roof is thus described by Savage 
(Female Pelvic Organs, 3d ed. p. 26): "A plane passing from the pos- 
terior surface of the pubis, about its middle to the junction of the 
third and fourth sacral bones — the sacral attachments of the utero- 
sacral muscles, cutting the uterus at the junction of the uterine body 
and uterine cervix, would upon the whole, with trifling exceptions, 
divide the pelvic cavity into peritoneal and subperitoneal cellular pelvic 
spaces." Also (p. 27) : " For the rest, as well remarked by Henle, the 
relations of the peritoneum with the pelvic organs above the pelvic 
plane exactly agree with the supposition that they were thrust up- 
wards against its under surface in attaining their respective positions." 
(See Figs. 1 and 2, pr and prp,) The result of this kind of support, 
viz., a suspension of the uterus near the junction of the corpus and 
cervix, is as if the uterine body rested on a ball-and-socket joint, and 
as if the neck hung from a support of the same character. Being- 
joined at the point of support the cervix and body must move together, 
although always in opposite directions. The plane of the pelvic roof 
holds this cervico-uterine plane in place, but does little to hold the 
fundus and external os in place. The upper portions of the broad 
and the round ligaments are the only direct support of the fundus, 
while the posterior wall of the vagina as applied by its own elasticity 
or by atmospheric pressure is the only direct support of the external 
os. But all checks upon the fundus act as checks upon the distal end 
of the cervix, whose action, however, is modified by the flexibility or 
rigidity of the uterus according to the case. The relation of abdominal 
pressure to the pelvic roof is one of the chief factors to be considered 
in the supports of the fundus, as will be explained hereafter. 

Relation of Uterus to Bladder. 

The uterus, which in early life is made up mostly of the cervix, and 
lies upon the posterior wall of the bladder, retains, in adult life, its 
original and main supports at the cervix where the peritoneum is 
reflected. As its body develops above the cervical attachment toward 
the peritoneal cavity, so as to deeply indent it and receive a peritoneal 



32 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

covering of its own, the bladder and cervix sink from the pelvic brim 
down into the pelvic cavity. The fundus uteri becomes loosely sus- 
pended in the broad ligaments, or folds of the indented peritoneum 
on either side, and is held forward over the bladder by the round or 
spermatic ligaments. It will thus be noticed that the uterus lies from 
the beginning against the bladder, and that the fundus is provided 
with no ligament to prevent it from resting upon the bladder until the 
broad ligaments are put upon the stretch. 

Relation of Pelvic Roof to the Pelvic Floor. 

As the heavy abdominal viscera are hung up in the abdominal 
cavity, and the weight of the remainder is not in a direct manner 
borne by the tilted pelvic roof, but little other support is necessary when 
the body of the individual is in a state of rest. But during muscular 
exertion a pressure equal to one or perhaps several hundred pounds 
is sometimes brought to bear upon it. Hence it is necessary that 
there should be a firm floor upon which the organs may be piled, and 
retained within the pelvic cavity until the extraordinary force ceases 
to act, and the retractility of the natural supports of the displaced 
organs can draw them back in position. Such a support is the pelvic 
floor. 

II. The Pelvic Floor. 

The pelvic floor is made up of the lower end of the sacrum, the 
coccyx, portions of the ischia, the sacro-sciatic and coccygeo-anal 




LESSER / 

SACRO-SCIATIC 

LIS. 



PUBIS, 



INTERNAL 
OBTURATOR 



LARGE SAC RC -SCIATIC LIG. 
Internal Obturator Muscle and Sacro-sciatic Ligaments (Tarnier and Chantreuil). 

ligaments, portions of the gluteal, internal obturator (Fig. 15), pyram- 
idal, levatores ani and coccygeal muscles with their fascia?, the recto- 



THE PELVIC FLOOR. 



33 



vesical, levator, obturator, etc., and some looser connective tissue. The 
upper surface formed anteriorly of the levatores ani, has a sort of 
resemblance to the shape of the bottom of a boat. (See Figs. 7, 18, 19.) 
Its centre in the meridian line is formed by the lower end of the 
sacrum, the coccyx, the coccygeo-anal ligament, and the meeting of 
the levatores ani muscles behind the rectum. This is the portion 
shown on the median sections (Figs. 1, 2, 3). The rectum is seen to 
pass down over it and then turn suddenly back, at the rectal promon- 
tory, to reach the anus. Such a section can, however, show but little 
of the pelvic floor and give but a very imperfect illustration of its 




gluteus 



coccyx 



Pelvic Floor Outlet and Vaginal Entrance. 

All tissue beneath it removed except rectum and anal sphincters. 

Rectum is seen passing forward under the pelvic floor and over its edge into the pelvic cavity 
p.f. e corresponds to pfe of Fig. 1. 

u. n., urethral notch; v., vagina; I. v., levator vaginae; e. I. a., edge levator ani; r. n., rectal 
notch; r. p., rectal promontory; r.. rectum; p.f. e., pelvic floor edge. 

complete relationship. From this rectal promontory, as a median sec- 
tion (Fig. 1, pfe) makes its lower border appear, the edges of the 
levator ani muscles pass up to the rami of the pubes like the sides of 
the letter V, forming the lower edge of the pelvic floor, as represented 
in Fig. 16 (edge levator ani), leaving an inverted triangular insuffi- 
ciency or outlet. The rectal promontory or anterior edge of the leva- 
tores ani in the median line thus represents the bottom or angle of 
the V. 

3 



34 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 



Relationship of the Muscles of the Pelvic Floor and Interposed Tissues. 

Fig. 17 gives a view of the attachment of the levator ani and the 
levator vaginae behind the pubes. Fig. 18 shows the levator vaginae 
of one side passing between the vagina and rectum as a small bundle, 
a continuation of the levator ani proper, which in turn passes to the 
lateral and posterior surfaces of the rectum, to the median line behind 
the rectum, and to the ano-coccygeal ligament and coccyx. It also 
shows the coccygeus muscle, which is the continuation posteriorly of 
the levator ani, spreading from a small attachment to the spine of the 
ischium like a half-expanded fan, towards the internal lateral edge 
of the coccyx. Fig. 19 portrays the superior aspect of these muscles, 

Fig. 17 




Pubic Attachments of the Levatores Ani et Vaginae Muscles (Savage). View from behind. 
S, symphysis pubis; U, urethra; V, vagina; 1, pubic attachment of bladder; 2, pubic attach- 
ment of levator vaginae; 3, line of attachment of levator ani; 4, pudic vein; 5, urethral-pubal 
venous plexus; 6, posterior face of perineal septum; 7, levator vaginae. 

constituting the main upper surface of the pelvic floor. The attach- 
ments anteriorly to the posterior surface of the pubic bones, laterally 
to the white line, or dividing of the pelvic fascia into the obdurator 
and recto-vesical, and posteriorly to the ischial spines, are plainly in- 
dicated. The median line attachments, also shown, must be consid- 
ered as a little more depressed below the level of the lateral attach- 
ments than would appear from a hasty glance at the figure. To get 
the plane of this muscular part of the pelvic floor which closes the 
bony pelvic outlet, and the part displaced or retracted in labor, com- 
pare with Fig. 7 (0- 



ABDOMINAL PRESSURE. 



35 



Above the levator plane lies the subperitoneal connective tissue 
chamber, below it the ischio-rectal fossa or vault (cavum ischio-rectale) 
filled with cellular tissue, affording, above and below, elastic support 
for the constantly varying plane of the pelvic floor, and guarding 
against any interference with, or from, surrounding organs. The 
ischio-rectal fossa stretches between the rectum* and ischium (Fig. 7) : 
its apex runs up along the levator ani muscle to the white line or 



Fig. 18. 




'S 6 

Muscles of the Pelvic Floor (Savage.) 
1, 2, levator ani; 3, eoccygeus; 4, white line (arcus tendineus, Luschka); 5, coccyx; 6, median 
line raphe; B, bladder; V, vagina; E, rectum; P, pubic symphysis. 

obturator attachment ; its base is the skin and superficial fascia from 
the lower edge of the perineal fascia (transversus perinei) in front, to 
the lower edge of the gluteus maximus behind. 

The pyriformis muscles, whose chief clinical importance lies in the 
fact that more important structures lie around and upon them, and 
that when contracted their bellies may be mistaken by the examining 
finger for more important structures, are situated farther back, behind 
the eoccygeus muscle and smaller sacro-sciatic ligament (Figs. 18 and 
19), and pass from the anterior surface of the sacrum about half an 
inch on either side of the median line, through the sacro-sciatic fora- 
men, to the major trochanter. 

Abdominal Pressure. 
The abdominal pressure, when the abdominal walls are relaxed or 
not strongly contracted, is considerably modified by gravity and by 



36 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC OKGANS. 



the elasticity of the pelvic tissues. During muscular activity it is 
partly reflected around the hollow of the sacrum in the direction of 
the pelvic axis curve, and partly exerted directly downward behind the 
symphysis pubis. In Fig. 20, the arrows indicate in a general way the 




Horizontal Section of Pelvis, giving a view of the Muscles of the Pelvic Floor from above. 

(Savage.) 
B, neck of bladder; V, vagina; R, rectum; P, pubic symphysis; C, coccyx; S, sacrum; A, acetabu- 
lum; 1, ant. vesical lig.; 2, 3, levator ani ; 4, white line; 5, coccygeus muscle; 6, smaller sacro-sciatic 
lig.; 7, pyriformis muscle; 8, obturator muscle. 

directions of abdominal pressure. The resultant of these two forces 
(the direct and the reflected pressure) which meet at the pelvic floor 
outlet from almost opposite directions, will be weak as compared with 
the original one, and will be through the V-shaped outlet (Fig. 20). 
The reflected pressure coming around the hollow of the sacrum, but 
for the pelvic floor projection, or rectal promontory in front of the 
coccyx, would be expended upon the anus, as indicated by the dotted 
arrow. But when this anterior edge of the pelvic floor is firm, it not 
only overlaps the anal region, but still farther reflects the pressure 
towards the apex of the pubic arch to meet the direct pressure higher 
up as indicated by the heavy arrows. With the forefinger in the 
vagina, curved so as to extend from the symphysis back toward the 



ABDOMINAL PRESSURE. 



37 



coccyx, and the thumb externally over the ano-coccygeal region, while 
the patient* stands and bears down forcibh 7 , we may detect the two 
forces, one depressing the coccyx and coccygeo-anal ligament, and the 
other the urethral region. 

This play of abdominal pressure on the muscles of the pelvic floor 
and perineum (which are voluntary muscles, and contract during any 
general muscular exertion) develops and strengthens them in propor- 
tion to the activity and development of the whole muscular system, 
and partly explains the presence of varying degrees of firmness of the 

Fig. 20. 




Illustration of the Action of Abdominal Pressure upon the Uterus (%). 
The dotted arrow indicates the direction of the strain upon the pelvic floor. The crossed 
arrows show the meeting of the direct pressure and that reflected by the pelvic floor. 

parts in different persons of the same age at their first confinement. 
The control of the pelvic floor by the will also explains how during 
excessive straining early in labor, before these muscles are stretched, 
the parturient is liable to firmly contract them and induce a state 
of artificial rigidity exceedingly difficult for her to overcome; and 
also explains how the pelvic floor may temporarily support with 
impunity, a pressure many times greater than that of labor, pressure 

* A nullipara with uninjured pelvic viscera must, if possible, be selected for this 
experiment. 



38 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

which without such voluntary contraction would overstretch all the 
ligaments of the pelvic organs and, if frequently repeated, lead to 
displacements * (See Fig. 21.) 

Requirements for the Closure of the Pelvic Floor Insufficiency. 

We are now prepared to understand the problem which is left to be 
solved, viz., to close up this V-shaped opening without interfering with 
the evacuations of the viscera or the progress of parturition. The 
abdominal pressure during muscular relaxation being but small in 
quantity at this point, and during muscular exertion almost entirely 
counteracted by the contraction of the pelvic floor, all that is called 

Fig. 21. 




Voluntary Contraction of the Pelvic Floor during Straining and Lifting (%). 
Uterus is carried down in the direction of the pelvic axis while the pelvic floor edge and 
perineum are drawn toward the pubis so as to close the pelvic outlet. Compare with Fig. 1. 

for to close the V-shaped insufficiency is a mass of tissue firm enough 
to support the walls of the outlets of the bladder, vagina and rectum, 
and elastic enough to allow of great distension without losing its 
power of retractility. This we have in the perineum, the classical 
object of wonder to the ignorant, and of confusion to the wise, yet 
whose only wonderful quality is its simplicity of structure and 
function. 



See "Control of the Pelvic Floor Muscles by the Will," p. 106. 



PERINEUM. 



39 



III. Perineum. 
The perineum or pelvic portico is an entirely supplementary support 
as far as the uterus is concerned. Constructed on a muscular frame- 



FlG. 22. 




Perineal Muscular System (Schematic). 
Iv, levator vaginas ; cc, constrictor cunni ; ps, perineal septum ; /, fourchette. 

work below the pelvic floor, it guards the pelvic floor insufficiency, 

Fig. 23. 




Dissection of the Muscles of the Perineum and Pelvic Floor (Savage). 

A, anus; B, bulb of vagina; C, coccyx; L, larger sacro-sciaticlig.; P, perineal body; U, urethra ; 

V, vagina; G, vulvo-vaginal gland; 1, clitoris; 2, its suspensory lig.; 3, crura clitoridis; 4, erector 

clitoridis muscle; 5, constrictor cunni; 7, transversus perinei; 8, sphincter ani, ext.; 9, 10, levator 

ani; 11, coccygeus; 12, obturator ext. 



40 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

and supports the projecting visceral outlets. During great abdominal 
pressure, labor, etc., the pelvic floor is brought in contact with the 
perineum and temporarily strengthened. This temporary union, 
having been so often observed by gynecologists and obstetricians, has 
led them to describe the pelvic floor and perineum as an anatomical 
and physiological unit, and has thus given rise to infinite confusion.- 
Fig. 22 shows its muscular framework in a schematic way. It will 
be seen that the levator vaginae, or vaginal sphincter, comes down 




Perineal Fascia laid open and part of the muscles cut out. Inferior surface of pelvic floor 
(levator fascia), forming the upper boundary of the ischio-rectal fossa. The fossa is shown with 
fatty connective tissue removed. 

a, gluteus maximus; Z, larger sacro-sciatic lig.; T, tuber ischii; A, anus; C, clitoris; M, urethral 
meatus; b, sphincter ani, ext.; d e, transversus perinei and constrictor cunni ; g, erector clitoridis; 
v, vagina; /, muscular fibres of perineal septum, the remainder scraped away; I, bulb partially 
cut away to show its sheath. 

from the internal or posterior surface of the pubis to be attached to 
the upper posterior part of the raphe in the median line at the vaginal 
entrance. It may be said to be hung (or fitted) in the pelvic floor in- 
sufficiency. The constrictor cunni or vulval sphincter (bulbo caver- 
nosa) comes down from the external or anterior surface of the pubis 
to be attached to the raphe in the vulva under the fourchette. Thus 
the upper part of the so-called triangle of the perineal body is pro- 



PERINEUM. 



41 



vided for. The transversus perinei comes from the tuberosity of the 
ischium to be attached to the same raphe between the sphhicter ani 
and the fourchette. The sphincter ani, attached posteriorly by a liga- 
ment (foreshortened in the illustration) to the coccyx, passes forward 
to the same tendinous raphe. Fig. 23 shows a superficial dissection 
of the parts. The perineal muscles are strengthened by the three 
layers of the perineal fascia which. coyer all but the sphincter ani, and 
pass laterally to the pubic rami. Fig. 24 shows them laid open, in dis- 
section. Between the two posterior layers of these fasciae, which are 

Fig. 25. 




Pelvic Floor and Perineal Fasciae. 
rv, recto-vesical fascia, internal layer of pelvic floor fascia ; I, levator fascia, external layer of 
pelvic floor fascia (see Fig. 31) ; ps, perineal septum, or triangular ligaments, the internal layers 
of perineal fascia ; el, external layer of perineal fascia. (In the median line the external or 
vulval layer of the perineal fascia is close to the perineal body as represented, but on either side 
it is a little more voluminous.) (For more exact relationship of the fasciae to the perineal body, 
see Fig. 31.) 

sometimes called the anterior and posterior layers of the triangular 
ligament, lies the constrictor urethra?, constituting with these two 
layers of fascia the perineal septum of Savage (Fig. 22). The lower 
portion or edge of the constrictor urethra? on either side, which is 
situated just behind the transversus perinei, is often called the trans- 
versus perinei internus. Fig. 25 shows the pelvic floor and perineal 
fasciae in median sagittal section. 

The sphincter ani is between the ischio-rectal fossae or vaults, but 



42 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

entirely below the pelvic floor. The perineum is connected with the 
pelvic -roof by the vaginal attachments of the levatores vaginas and the 
perineal fascia?, and to the pelvic floor by the ano-coccygeal ligament, 
and by the fascial coverings and pubic attachments of the levatores 
ani et vaginae. The perineum is separated from the pelvic floor by the 
ischio-rectal vault (Fig. 7) and the backward curve of the rectum from, 
the rectal promontory, or pelvic floor edge, to the anus (Figs. 1 and 2). 
The pelvic floor lies as a whole within or above the external conjugate 
or pubo-coccygeal line, while the perineum lies below or external, al- 
though their points of meeting lie anteriorly above and posteriorly at or 
a trifle below it. Hence I would call the projection of these parts below 
the external conjugate, not the pelvic floor projection (Schrceder, Foster, 
Hart and Barbour, etc.), but the perineal area or projection. This pro- 
jection varies with the age, weight, muscular vigor, and the position of 
the woman, as well as with the condition of the parts, as resulting from 
pregnancy, child-bearing, inj ury , or local disease. My conclusions, based 
upon examinations and measurements, would make Foster's estimate 
of one inch (2.5 centimetres) a liberal average for healthy women, the 
healthy extremes being about half an inch and an inch and a half. 

Perineal Body. 
The convergence of the perineal muscles and fascia about the median 
line raphe forms what has been called the perineal body. The rectum, 
curving backwards between the perineum and pelvic floor, gives the 
body the shape of a muscular band a little thicker anteriorly than poste- 
riorly, and about an inch and a half long, stretched across the pelvic 
floor outlet or insufficiency. Its inner surface is covered by the rectum, 
its outer by the skin, and its upper by the skin and mucous membrane 
of the vulva and introitus vaginae. Quite a quantity of cellular tissue, 
continuous with the ischio-rectal vaults, is found under the rectal sur- 
face, and a smaller quantity under the skin at the posterior commissure. 

Measurements of the Perineal Body. 
The median line raphe" is about one-eighth of an inch (30 mm.) in 
width. A median section through it shows what has been called the 
perineal triangle (Fig. 1). Fig. 26 shows, by means of dotted lines, 
the shape of the raphe in the triangle, natural size. I have measured 
the perineal triangle in five young virgins ; ten married women, be- 
tween twenty and forty years old, who had either not yet conceived, or 
had miscarried under three months; and two married women of fifty 
and fifty-four years respectively. The accompanying table represents 
the average measurements of the sides of the triangles in these cases : 

5 virgins. 10 married 2 senile 

multipara. multipara. 

Vulvo-vaginal side, . f l ^ and f 

Cutaneous side, lj i£ 1J and ]£ 

Eectalside, if i| If and If 



CHARACTERISTICS OF THE PERINEAL BODY. 



43 



The first measurements of the senile cases belonged to a small thin 
sterile woman fifty -four years old ; the other to a fleshy one about 
fifty, who claimed to have had miscarriages. Figs. 26, 27, and 28 
represent the perineal triangle as constructed from these figures. 

Characteristics of the Perineal Body. 

The character of the perineal body as a support is derived from 
the perineal muscles and the double layer of internal perineal fasciae, 
the perineal septum ; and its shape varies with their tension and firm- 
ness. In many virgins of firm muscular fibre the fourchette is pulled 



Fig. 26. 



Fig. 27. 




: cc 

Perineal Triangles of Virgin (life size). 
Fig. 28. 

Ct 




ct 



Married Nulliper. 
Fig. 29. 





CO 



Old Woman, 50-54 years. Old Maid before Menopause.* 

r. rectal side ; ct, connective tissue ; h, hymen; /, fourchette; pc, posterior commissure; a a, 
sphincter ani. Dotted lines indicate size and shape of tendinous raphe. 

up so as to form an acute angle (Fig. 26), while in married women 
the relaxation of the constrictor cunni usually drops the fourchette so 
as to form a right or obtuse angle (Fig. 27). Contraction of the levator 
vaginae draws the hymen, which seems to be a continuation, or per- 
forated edge, of the posterior triangular ligament or perineal septum, 
into the pelvic floor outlet, so as to stretch the posterior commissure 
over the edge of the tendinous raphe, and round off or flatten the 
angle (Fig. 29). Great relaxation of the whole perineal structure 
produces a sagging of the tendinous raphe as indicated in Fig. 30. 
Fig. 31 illustrates the relative positions of the muscles and fascia? in 
the perineal body. 



* This form also occurs in the young who have irritable or tight sphincters. 



44 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 



Fig. 30. 



Action of the Perineum as a Support. 
The resisting power of the perineum varies with the character and 
direction of the force acting upon it. If a destructive pressure bears 

upon it so as to put all its muscles 
upon the stretch to an equal degree* 
the median raphe will be the first- 
portion to part asunder. When any 
muscle or pair of muscles are sub- 
jected to a greater strain than the 
others, such muscles must usually 
give way before the raphe. Calling 
the sphincter ani the apex of the 
perineal triangle or pyramid, its base 
is in relation with the urethra in 
front. Its greatest efficiency as a sup- 
port is to a force or weight bearing or resting upon the base or vulvo- 
vaginal side, for the resisting powers of the levator vagina?, constrictor 
cunni, and, later, the transversus perinei are enlisted, and the fasciae 

Fig. 31. 




Shape relaxed Perineal Triangle (\). 




Relations of Muscles and Fasciae to Perineal Body (\). 
cc, constrictor cunni or vulval sphincter; tp, transversus perinei; rp, rectal promontory or 
pelvic floor edge ; Iv, levator vagina or vaginal sphincter ; ps, perineal septum ; If, levator fascia 
and posterior layer of perineal septum ; el, external layer of perineal fascia ; rv, recto-vesical or 
the internal or visceral layer of the pelvic fascia ; is, internal sphincter ani ; a a, sphincter ani. 

are stretched in a direction almost parallel to their surfaces (Fig. 31). 
Pressure from the apex or rectal side meets the resistance of the 
sphincter ani, transversi perinei, and lower or posterior edge of the 
perineal fascia. 

The ordinary reflected abdominal pressure is deflected from the 
rectal promontory of the pelvic floor, so that the perineal body re- 
ceives the final resultant near its base, or stronger portion (Fig. 20). 
If the pressure, however, be through a fluid or semi fluid medium in 
the rectum, it will be exerted around the pelvic floor edge or rectal 
promontory, and have only the resistance of the sphincter ani to 
overcome. If it be exerted through a large solid body of conical 
shape in the vagina, as in labor, the levator vaginae will be pushed 
downwards and backwards with the levator ani, and the perineal 



ACTION OF THE PERINEUM AS A SUPPORT. 



45 



body doubled or folded upon itself at the posterior commissure, or a 
point just external to the relaxing constrictor cunni (Fig. 32), and a 
folded or double tendon will be opposed to the descending occiput to 



Fig. 




Folding of the Perineal Body in Normal Labor when Dilated by means of the Bag of Waters or 

Caput Succedaneum {%). 
The dots on the perineal body indicate connective tissue containing fat. 
p. c, post, commissure ; e. c. c, edge constrictor cunni or vulvar sphincter ; e. I. v., edge levator 
vagina? or vaginal sphincter; a., anus ; e.l.a., edge levator ani ; e.l.c, edge levator coccygei ; 
e. c, edge coccygeus ; s. s. L, smaller sacro-sciatic ligament. 

direct it up through the dilating vulva. The pressure upon the peri- 
neal body will be from base to apex. The internal perineal fascia 
(perineal septum) will be stretched in a direction parallel to its sur- 
faces, and will suffer but moderate attenuation, or loss of resisting 
power. In cases of rigidity of the perineal tissues in labor, or in 
absence of a suitable dilating cone or wedge, such as the pouch of 
membranes or a large caput succedaneum, the levator ani will still be 
pressed back by the head, but the levator vaginse and constrictor 
cunni, not being thus pushed back, will be pressed forward before 
the head, away from the levator ani, and in a direction at right angles 
to their plane of contraction, and will swing out or bulge at their 
perineal or movable attachments in proportion to the stretching of 



46 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 



the lower weaker portions of the perineum (Fig. 33). The anterior 
edge or base of the perineal body will thus be left to be pulled back 
by the stretched, and depressed lower portions. Already torn from 
its connective tissue relations with the levator ani and rectum, the 



Fig. 83. 




Flattening of the Perineal Body in Labor due to rigidity of the outlet or improperly directed 

force (%). 

p. c, post, commissure; e. c. c, edge constrictor cunni; e. I. v., edge levator vaginae (Hymen); 
«., anus; e. I. a., edge levator ani; e. I. c, edge levator coccygei; e. c, edge coccygeus; e. s. s. L, edge 
smaller sacro-sciatic ligament, 

perineum is drawn and flattened into a thin membrane with the line of 
advance (or pelvic axis) passing through it, somewhere near its centre. 
As injuries of the perineum and pelvic floor are largely due to the 
pressure of the head in labor, an understanding of the various changes 
occurring in the perineum during labor is necessary to a full under- 
standing of the different lesions of the parts and their restoration to 
normal relationship. 

The Rectum. 
^ The female rectum is an organ of great interest to the gynecologist, 
since for almost the whole eight inches of its length it is in intimate 
relation with the generative organs. Just inside of the external sphinc- 



THE RECTUM. 



ter ani, the circular muscular fibres of its middle coat form a supple- 
mentary or internal or second sphincter (Fig. 34). From the anus, 
the rectum passes forward directly behind the perineal body (Fig. 31), 
making a very small angle with the horizon until it reaches the poste- 
rior vaginal wall and recto-vaginal angle of the perineal triangle, an- 
teriorly, and the pelvic floor edge or rectal promontory, posteriorly. 

Fig. 34. 




Muscular Fibres of the Rectum. 
Rectum of a male subject, cut open longitudinally, and the mucous membrane dissected off so 
as to show the circular muscular fibres. DD' correspond to same letters in Fig. 35, and indicate 
the aggregation of fibres constituting the anterior and posterior segments of the superior Detru- 
sor Fsecium (Third Sphincter). S, is the inferior Detrusor Fsecium (Internal Sphincter). A, Anus ; 
f and * correspond to same marks on Fig. 35. This drawing shows the muscular fibres passing 
from the anterior to the posterior segment of the superior Detrusor, by the action of which they ' 
may be approximated to each other.— (After Chadwick.) 

It then takes a sudden turn up around the pelvic floor edge, in through 
the pelvic floor outlet or insufficiency, and, bearing a little to the left, 
passes backwards again at an acute angle with the horizon (Fig. 1) 
along the coccygeo-sacral groove. At this lower turn or promontory 
of the rectum, the levator ani, when contracting, draws the bowel for- 
ward against the anterior vaginal wall and practically constitutes a 



48 AX ATOMY AND PHYSIOLOGY OF FEMALE PELVIC OPvGAXS. 



third sphincter. After passing under and a little to the left of the 
cervix the rectum curves up behind the uterus between the sacro- 
uterine ligaments or folds. Its lateral deviation corresponds with the 
twisting of the uterus upon its axis so as to bring the left side a little 
in front of the right. The rectum, receiving its peritoneal covering 

Fig. 35. 




Distended Rectum. 
Rectum from a male subject tied below at the anus and inflated. DD' are the anterior and pos- 
terior segments of the superior Detrusor Faecium (Third Sphincter). R is the ampoule rectale, f and 
* correspond to same marks in Fig. 34. This drawing shows the sinuosities of the rectum main- 
tained by the action of the longitudinal fibres at the points where the circular fibres are collected 
in bundles, notably the two lower ones.— (After Chadwick.) 

over the anterior and lateral surfaces at the Douglas cul-de-sac and 
sacro-uterine folds proceeds upward to join the sigmoid flexure of the 
colon near the left sacro-iliac synchondrosis in the false pelvis. 

It is normally empty and lies on its bed as an irregular or flattened 
cylindrical mass of movable tissue, partly filling the pelvic floor out- 
let so as to press the posterior vaginal wall against the anterior (Fig. 
16). It is attached by loose connective tissue to the vaginal wall as 
far back as the cul-de-sac of Douglas or recto-uterine peritoneal pouch 



THE RECTUM. 49 

and as for back as the coccyx is held in position by the action of the 
levator ani. Where the rectum curves up behind the cervix, and just 
under or behind the sacro-uterine folds, an augmentation of the cir- 
cular muscular fibres on its anterior surface produces a slight semi- 
circular band or constriction, which, when rigid, may be mistaken 
during " digital " examination of the rectum for the semicircular out- 
line of the sacro-uterine folds. Fig. 35 gives the appearance of this 
constriction (J)) in the inflated male rectum, removed from the body. 
In the healthy relaxed female rectum, in the living subject, these con- 
strictions, lying in the rectal folds, are not always easily felt. Just 
above this anterior constriction is another on the posterior side (D').* 
Fig. 33 represents the course of the muscular fibres through these 
parts. When both bands are contracted they do not completely close 
up the rectum, but are apt to be approximated in such a manner as to 
overlap and close the passage, and constitute, in an imperfect manner, 
a fourth sphincter which may give the examining finger some trouble 
in finding its way past them. According to Chadwick, during the 
rhythmic contractions of the rectum these constrictions or half sphinc- 
ters contract separately and consecutively so as to aid in expelling the 
faeces. As will be seen in Fig. 34, these constrictions are merely con- 
tinuations and exaggerations of smaller constrictions above, all of 
which act to hold the faeces firmly while passing them on, and are 
admirably adapted to prevent over-distension of the gut by agglom- 
erated excreta. In the pouch, between the rectum and uterus, are 
often found intestinal folds and peritoneal fluid. 

It will be readily perceived how, although normally empty, the 
rectum, at the bottom of the subperitoneal chamber and in direct 
relationship with the uterus, the sacro-uterine peritoneal folds and sub- 
jacent tissue, is apt, during even moderate distension by gases and de- 
scending faeces, to press injuriously upon the pelvic tissues that are in 
a state of inflammation ; and also why it so frequently becomes the 
avenue of escape of pus from pelvic abscesses. At the left sacro-iliac 
synchondrosis, the sigmoid flexure of the colon, or fifth sphincter of 
the bowel, marks the region above which freces are normally lodged. 
When this portion is over-distended the fecal tumor may so press 
upon the uterus and its surroundings as to weaken its supports, dis- 
turb its circulation and interfere with its nervous supply. The pas- 
sage of fecal matter from the csecal valve (sixth sphincter) through the 
colon to the rectum is normally a slow one, and in females of seden- 
tary or indolent habits is often accomplished with great delay and 
difficulty. The result is a continuous state of fulness of the lower 
terminus and sometimes of almost the whole extent of the colon, with 
its baneful influence. The late Dr. J. S. Jewell,f of this city, has re- 



* Transactions Am. Gynecological Soc, vol. ii., p. 
f Transactions Chicago Medical Society, 1886. 
4 



43. 



50 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

moved, inside of thirty hours by means of bland enemata and mas- 
sage, two gallons of fecal matter from the colon, over and above the 
quantity introduced into the bowels. The almost immediate relief 
from cold feet, indigestion, offensiveness of the cutaneous secretions, 
muddiness of complexion, nervous depression, etc., and the astonish- 
ing fact that he has . records of over five hundred cases of a similar 
kind, would make it appear that disorders of the colon and rectum 
are more important factors in the etiology of uterine diseases, and 
the accompanying symptoms, than has been generally suspected. 

The Bladder. 

The bladder in the female is largely supplied by the same vessels 
and nerves as are the generative organs. Connected with the vaginal 
wall below and the uterus behind, it is more exposed to injury than 



Fig. 36. 




Relation of the Ureters to the Bladder and Uterus 



(Luschka) 



in the male, and at the same time is more easily accessible for surgical 
treatment. When empty it is drawn together in a flattened, flabby 
mass, lying between the anterior vaginal wall, symphysis pubis and 
corpus uteri (Fig. 1), and projects into the para-vesical pouches. As 
it becomes filled with urine it tends to press the fundus upward and 



BLOODVESSELS. 51 

backward toward the pelvic axis (Fig. 3). In so doing it also presses 
back the internal os a little, so that while the external os is turned 
forward by the rising fundus, it remains in nearly the same location. 
If the corpus uteri be heavy, or the fundus deprived of its usual 
mobility, the filling bladder becomes indented by it, and rises on both 
sides of the uterus, or if the fundus be drawn to one side rises on the 
opposite side, and thus forms either one or two fluctuating tumors later- 
ally situated. When greatly distended the bladder rises over the 
symphysis pubis, pushes up the small intestine and lower edge of the 
peritoneum and impinges against the abdominal walls. 

The trigone (Fig. 36) lies over the anterior vaginal wall. Its base, 
the inter-uretric ligament, is from an inch to an inch and a half in front 
of the cervix, and may be felt as a ridge between their vesical open- 
ings. Its apex is from an inch to an inch and a half beyond the 
meatus urinarius at the opening of the urethra into the bladder. 



The pelvic connective tissue is traversed by vessels which run 
tortuous courses, and anastomose freely, and therefore accommo- 
date themselves easily to the great stretching and displacement to 
which such tissue is sometimes physiologically subjected. The largest 
bloodvessels of the female genital organs are situated posteriorly on 
either side (Figs. 8 and 9) and in the broad ligaments. The internal 
iliac artery comes down from the pelvic brim and divides above the 
upper border of the greater sacro-sciatic foramen behind the sacral 
pouches. The branches found in the pelvis from the anterior trunk 
are : the superior vesical passing under the peritoneum and, after 
giving off the middle vesical to the bladder, continuing as the oblit- 
erated hypogastric artery ; the uterine, passing into the broad ligament 
above the spine of the ischium, giving off the vaginal artery near the 
cervix, and sometimes the middle hemorrhoidal; the obturator, pass- 
ing over the ischial spine forward to its point of exit from the pelvis 
at the upper anterior portion of the muscle of the same name, and 
giving off branches anteriorly to the pelvic brim and pubis ; the middle 
hemorrhoidal, passing along the upper surface of the pelvic floor in- 
wards and forwards to the rectum — often giving off, near its origin the 
inferior vesical ; the internal pudic, passing out between the coccygeus 
and the pyriformis muscles ; and the sciatic, passing out between the 
same muscles, but just behind and internal to the pudic, between the 
first and second sacral nerves. The main branch of the posterior 
trunk is the gluteal which leaves the pelvis just behind or above the 
edge of the pyriformis muscle and first sacral nerve. The ilio-lumbar 
branch, given off at the pelvic brim, passes back to the lumbar region 
and iliac fossa anastomosing with the last lumbar artery, the glu- 



AXATOMY A>~D PHYSIOLOGY OF FEMALE PELVIC ORGANS. 



teal, circumflex iliac, external circumflex and epigastric arteries. — 
(Gray). 

The rectum does not lie against any of the large arteries, below the 
upper edges of the sacro-uterine folds ; above them it passes over the 
left iliac. It has no large arteries upon its anterior surface except the 
hemorrhoidal which can be easily felt by the finger, and avoided in 
operations. Behind the rectum high up lies the sacra-media. 

The ovarian or spermatic arteries, branches of the abdominal aorta, 
do not enter the true pelvis, but pass over the brim between the folds 
of the broad ligaments to the ovaries and upper portion of the 



Fig 




Distribution of the Ovarian, Uterine and Vaginal Arteries— (Hyrtl). 

uterus. The uterine artery passes into the base of the broad liga- 
ment, not far from the spine of the ischium, across to the side of the 
uterus near the internal os, and then up between the fold? of the 
peritoneum to anastomose freely with the ovarian artery (Fig. 37). 
The internal pudic passes out of the subperitoneal connective tissue 
chamber and the pelvis through the greater sacro-sciatic foramen, 
across the ischial spine externally, enters the ischio-rectal vault 
through the lesser sacro-sciatic foramen, passes across the inner sur- 
face of the tuberosity and ramus of the ischium, up along the pubic 
ramus to the perineum and vulva. The obturator arteries frequently 
arise from the posterior branch of the internal iliacs. The veins of the 






LYMPHATICS. 53 



pelvis follow the arteries, and are particularly abundant between the 
layers of the broad ligament external to the arteries, and in the pos- 
terior wall of the vagina. They are unprovided with valves and apt 
to bleed excessively when cut of ruptured. 

Nerves. 

The spinal nervous supply of the pelvis is derived chiefly from the 
sacral plexus, the fourth and fifth sacral, and the coccygeal nerves. 
The sacral plexus lies upon the anterior surface of the pyriformis 
muscle. The pudic is given off from the sacral plexus, and with its 
hemorrhoidal and three perineal branches affords the chief nervous 
supply to the perineum, vulva and vagina. The small sciatic supplies 
the integument of the perineum. The fourth and fifth sacral, coccy- 
geal and hemorrhoidal branches supply the pelvic floor. The hypo- 
gastric plexuses and lower ganglia of the sympathetic nervous system 
supply the internal pelvic organs, and are particularly liberal in their 
allowance to the uterus and its appendages. The uterus itself depends 
for its spinal nervous supply upon the filaments that accompany the 
sympathetic nerves, and is, therefore, in the unimpregnated state, 
almost devoid of ordinary sensation, and can be subjected to great 
irritation and even affected with organic disease without giving ap- 
parent inconvenience to the system. It seems to require a participa- 
tion of the peritoneal or flbro-cellular surroundings of the uterus, or a 
sufficient change in its submucous and muscular substance to decidedly 
interfere with the functions of these nerves, or else an abnormally 
debilitated state of the nervous tissue, for the production of any appre- 
ciable resentment on the part of the general nervous system. How- 
ever, let this vast accumulation of nervous elements finally become 
involved in pathological changes, and the lack of sensibility will not 
prevent the most profound, far-reaching, mysterious and often disas- 
trous reflex effects. The abundance of the spinal nerve supply to the 
perineum, pelvic floor and vulva, explains how uterine and ovarian 
irritation, congestion and inflammation, instead of being felt at their 
seats, may be symptomatized by a reflected irritability of the sphinc- 
ters, by pruritis vulvas et vaginas, vaginismus, coxalgia, etc. 

Lymphatics. 

Lymphatic glands are chiefly found about the cervix uteri, in the 
upper portion of the pelvic connective tissue chamber, behind the 
broad ligaments and on the sacrum at either side of the rectum, be- 
tween the large bloodvessels, and along the obturator artery. Lym- 
phatic vessels are abundant everywhere in the pelvis. Those about 
the cervix communicate directly with the connective tissue chamber 
and lower portion of the broad ligament. Hence infection from the 



54 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. 

cervix is apt to lead to pelvic abscess, while infection from the uterine 
body may give rise to extensive peritoneal inflammation without sup- 
puration. 

For the structural anatomy of the pelvic viscera and external genitals, the student 
is referred to the text books upon anatomy and histology. Space does not here permit 
a repetition of these things, which are, or should be, a part of the mental equipment 
of every graduate in medicine. 






CHAPTEK II. 

EXAMINATION OF THE FEMALE PELVIC ORGANS. 



Fortunately for suffering woman, we may arrive at demonstrative 
knowledge of the locality of her several pelvic organs and of the 
nature and extent of the diseases which affect them, and consequently 
treat them with the certainty which a positive diagnosis always in- 
sures. The evident advantages of a physical diagnosis will render it 
quite unnecessary for me to use any argument in favor of it, or to in- 
duce medical men to resort to it. A physical examination, however, 
of the genital apparatus of females, is quite a different matter from a 
physical examination of the chest, eye, or ear, or any other organ of 
the body ; and hence the necessity of approaching and conducting it 
under conditions rendered imperative on account of the circumstances 
connected with it. The education and natural sense of modesty, so ap- 
propriate to female character, and which always commands the respect 
of gentlemen, make such examinations disgusting and disagreeable above 
almost all others demanded by the necessities of woman's circum- 
stances. With a view to this fact, it is our duty, by our conduct 
toward our patient, and the management of the examination, to divest 
it as nearly as possible of every disagreeable feature. Medical men 
generally, I think, are, as they should be, actuated by the above consid- 
erations, and I fear that they are often so influenced by their own sense 
of delicacy as too frequently to abstain from the enforcement of essen- 
tial investigations. This is an error we should always bear in mind, 
and, I think, we shall less frequently regret a thorough, although 
somewhat indelicate examination when dictated by an honest and 
intelligent conviction of its necessity, than a neglect of such exam- 
ination from too great a deference to a sense of shame. We should 
not, in important cases, take things for granted. 

Our bearing to a female patient should be deferential, candid, and 
modest. She should be convinced by our demeanor that everything 
we do and say is strictly necessary and relevant to her case, and has 
its foundation in our solicitude for her welfare. Nothing, therefore, 
should be said or done but what is called for and obviously proper. 
This sort of treatment from her medical adviser will always command 
the confidence and earnest co-operation of an intelligent female pa- 
tient. There should be a full and explicit understanding, when pos- 
sible, between the physician and the patient, as to the necessity of a 
physical examination, in what it consists, and how it is to be conducted. 
The good sense of the practitioner will enable him to judge whether 



56 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

he should commit the detail of explanation to the husband, or some 
other appropriate second party, or whether he impart it directly to the 
patient ; all the circumstances of the case will enable him to determine 
this matter without much difficulty. After the preliminaries are dis- 
posed of I would insist upon conducting the examination without 
exposure. It is needless in ordinary uterine examinations, and should, 
be permitted only when the disease is upon the external parts. One 
position and kind of preparation, so far as the patient is concerned, 
will suffice for most cases, whether we wish to make a manual or an 
instrumental examination. There is no necessity for the patient to 
unclothe herself. 

Position of Patient for Examination. 

In the ordinary work of an office I think there is nothing more con- 
venient than Wilson's chair. It can be made to assume so nianv forms 




-aicago. 
Operating Chair. 



that it can be used as a chair or table either, and is easily moved into 
any position in relation to the light. 

For many purposes, however, a table will afford us more satisfaction. 
It is very much to be preferred in surgical operations. 

While the gynecological table represented in Fig. 39 is very conve- 
nient for an office, an ordinary table such as can be found in any 
dwelling can be made to answer every purpose. 

There are three positions of which we may avail ourselves in making 
examinations or performing operations: the dorsal, the latero-abdomi- 
nal. or Sims'e position, and the knee-chest position. 

In the ordinary dorsal position the patient is placed on her back 
with the breech very near the end of the table or chair, the knees 



POSITION OF PATIENT FOR EXAMINATION. 



57 



flexed and the thighs drawn up close to the abdomen, the feet resting 
by the side of the nates or in the stirrups, and the shoulders elevated 
upon pillows. In this position the abdominal walls are relaxed and 



Fig. 39. 




Byford's Operating Table. 



brought near the pelvic organs (Fig. 44), and both hands may be used 
with great freedom in exploring them. 

It is, in fact, indispensable to a perfect bimanual examination, and 
is very convenient for the use of the sound, and almost every form of 



Fig. 40. 




Position for Sims's Speculum. 

speculum. Even Sims's speculum can be made to do effectual service 
in this position. 

For many minor operations and uterine applications it is a very 
convenient position. This was a favorite position with the late Pro- 
fessor Simon. When the hips and shoulders are greatly elevated, the 
knees extended, and thighs forcibly flexed upon the abdomen, this is 
called Simon's position, and is not inferior to any other for examination 
or surgical operations on the vagina and uterus. 



58 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

Sims's position consists in placing the patient on her left side, with 
the left arm under and behind the body, and both knees drawn up close 
to the abdomen ; the right, flexed to a greater degree, and overlying the 
left, rests on the table in front (Fig. 40). The abdomen becomes some- 
what dependent and draws the pelvic organs away from the external 
outlets. When the perineum is drawn back the vagina is distended 
by atmospheric pressure, and the vaginal wall and uterus brought into 
view. 

The knee-chest position is also Sims's position, and produces the 
same effect in dilating the vagina obtained by the other, only perhaps 
in an exaggerated degree (Fig. 92). 

Percussion of the Pelvic Organs. 

Percussion gives us but little information concerning the healthy 
pelvic organs, but may be valuable in determining the absence of 
such enlargements and misplacements as are known to bring them 
within the field of such an examination. 

Intestinal resonance usually exists over the pubes, but during great 
distension of the bladder is replaced by dulness, extending some- 
times almost or quite to the umbilicus. In case such dulness be due 
to a distended bladder, firm pressure will produce a feeling of tension 
or pain on the part of the patient at the neck of the bladder, or a 
sensible depression of the anterior vaginal wall, or fluctuation, upon 
a finger placed in the vagina. 

An accumulation of fasces high up in the rectum often produces a 
decided dulness on percussion over the left iliac region. 

Palpation of the Pelvic Roof — Digital Examination through the Vagina. 

The mode of examining the pelvis with the fingers is of the utmost 
importance. After oiling the fore and middle fingers (Fig. 44) the 
index should be very gently introduced, and the examination con- 
ducted as far as possible with it ; then the two may be introduced 
and nearly all of the cavity of the pelvis explored. The index finger 
will not reach as far as the two together, but it is more delicate and 
intelligent in touch, and is less hampered by vaginal resistance. 

The rectum, as it curves over the pelvic floor edge into the pelvic 
cavity, lies immediately under and to the right* of the finger. When 
partly filled with faeces it is felt as a soft round ridge upon the floor 
and posterior wall of the pelvis, when empty as a loose or easily dis- 
placed fibrous cord or bundle of cords ; or it may be almost unrecog- 
nizable through the resistant vaginal walls and surrounding connec- 
tive tissue. Sometimes one or more hard fecal lumps just below or 



Left side of the patient. 



THE CERVIX UTERI OF THE CHILD-BEARING WOMAN. 59 

behind the cervix uteri, in an otherwise empty rectum, will indicate 
its course ; at other times a fecal mass as large as an egg will project 
from the pelvic floor in front of the cervix ; or a large accumulation 
may be felt, tumor like, behind and over the uterus. 

Inflammation, induration, or stricture of the rectum will be re- 
vealed by sensitiveness, hardness, or a point of contraction. Indeed, 
this easy and painless method of examining the rectum, and elimi- 
nating as far as possible, rectal disease from our diagnoses in gyneco- 
logical cases, should receive careful attention and study. 

Next we should turn our finger forward, pass it up behind the 
symphysis pubis, and along the front wall of the vagina, and as defi- 
nitely as practicable ascertain the condition of the bladder. The 
examination is more complete if the fingers of the left hand are 
pressed into the pelvis just above the symphysis pubis, and approxi- 
mated to the finger behind the pubis. Any foreign body, morbid 
deposit, displacement of the bladder from its median position, any 
thickening, inflammation or hyperesthesia of its walls, etc., can thus 
be detected. 

Characteristics of the Cervix Uteri. 

After palpating the rectum and bladder we should, as a starting- 
point to a farther exploration of the pelvis, locate the neck of the 
uterus. 

In passing through the vaginal canal, the uneducated finger is im- 
pressed with a soft intestinal sensation, and can distinguish nothing 
but loose folds, that are dissipated and lost in the surrounding soft- 
ness by the slightest pressure, until it comes to the neck of the uterus, 
which has consistence enough to retain its shape under considerable 
pressure. If pushed upward, backward, or downward, it retains the 
same characteristics. The finger can be carried up beside, before, or 
behind, and around it in every direction except above. This, being 
unlike anything else in the vagina, will be easily recognized. 

The Virgin Cervix. 

The virgin cervix uteri is almost cylindrical in shape, slightly 
compressed from before backward, and not far from three-quarters of 
an inch in diameter in every direction. It projects half to three- 
quarters of an inch into the vagina, a little deeper behind than in 
front (Fig. 41). It points toward the coccyx, and at the projecting or 
free end is apparently cut nearly square off, so as to present almost a 
fiat surface, with a dimple in the centre corresponding to the os uteri. 

The Cervix Uteri of the Child-Bearing Woman. 

The cervix uteri of the child-bearing woman is about an inch wide, 
or often a little more, and from half to three-quarters of an inch in 



60 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



its anteroposterior diameter. Instead of being truncated it feels as 
if formed of two projections at its inferior extremity, the anterior and 



Fig. 41. 




Virgin Uterus and Vagina. 



posterior labia separated by a distinct fissure, which runs transversely 
and represents the os (Fig. 42). 



The Senile Cervix. 

The os uteri in advanced age does not project into the vagina, and 
often feels more like a pit at its termination (Fig. 43). There is often a 
cord or frsenum-like projection in the vaginal walls, which is planted 
into the external surface of the anterior and posterior lips of the 
mouth of the uterus, and thus extends backward and forward to be 
lost in the anterior and posterior median lines of the walls of the 
vagina. This fraenum becomes more apparent, if not more developed, 
as women advance in age ; but I have known it to be so prominent 
as to be mistaken for disease, even in the middle aged. In one case 
an intelligent practitioner thought it an evidence of the injurious 
effect of strong caustics. 

The consistence of the virgin and parous cervix uteri is the same. 
To the sense of touch it gives the idea (which is a correct one) of 



LOCATION OF THE CERVIX UTERI. 



61 



deep fibrous tissue, almost as hard as cartilage, covered over thickly 
with areolar tissue. Dr. Bennett compares it to the feel of the cartilage 



Fig. 42. 



Fig. 43. 





Uterus of the Child-bearing Woman. 



Senile Uterus and Vagina. 



of the lower end of the nose. It seems to me not quite so dense,, 
although nearly so. 

Location of the Cervix Uteri. 

The location of the cervix varies with the position of the patient. 
When she stands erect its anterior wall is at or a little back of the 
axis of the superior strait, and hence about two and a half inches, or 
a little farther, from the inferior pubic ligament. When she assumes 
the dorsal position the lower end of the cervix is, on account of the 
altered abdominal pressure, from a quarter to a half inch nearer to 
the vulva. In the Sims's position the cervix is drawn farther away 
with the receding abdominal viscera. 

If, in the dorsal position, the index finger be introduced along the 
anterior vaginal wall until the middle of the third phalanx just 
touches, or is a little beyond, the inferior pubic ligament, the anterior 
wall of the cervix (Fig. 44) will be touched. By raising the finger 
well up at one side of the urethra the exact place of impingement 



62 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



against the ligament can be felt, and the distance measured. Passed 
on under the cervix the finger end will have the os upon it, and the 
rectum immediately under it. 

The distance between the os and the coccyx, after pushing aside 
the rectum, should be about equal to double the thickness of the 
finger, i.e., the finger should occupy half of the space. In child- 
bearing women the os is usually down a little nearer to the coccyx, in 
old women up a little farther from it. 

On either side of the cervix the finger should pass nearly an equal 
distance outward before encountering the ischial bones ; or if the sur- 
rounding tissue be firm, should encounter only elastic resistance on 
either side. When much lateral displacement is present, the finger- 



FlG. 44. 




Digital Examination in the Dorsal Position.— Touching the Cervix QyQ, 



tip beside the lower end of the cervix, finds the pelvic wall so near as 
to leave space for but little lateral motion on one side ; while on the 
opposite side it may move about freely, and reaches bony resistance 
only after being pressed two or three times as far from the cervix as 
was possible on the side of the displacement. A slight amount of 
lateral displacement may be more easily estimated by laying the 
finger end on the coccyx, and then raising it up until it touches or 
glides by the cervix. With the finger tip against the cervix, and the 
finger touching the inferior pubic arch, first in one urethral notch. 
and then in the other, the distance from the notch to the cervix is 
less on the side to which the latter is displaced. 



PALPATION OF THE DISPLACED UTERUS. 63 

Corpus Uteri. 

When the uterus is normal in size, shape and position the finger in 
the vagina may be pushed high up in the fornices without encounter- 
ing any check except the elastic counter-pressure of the vaginal walls 
and surrounding connective tissue. The hard body of the uterus, 
when the bladder is empty, may be felt for a short distance along the 
anterior vaginal walls, gradually receding forwards and upwards 
beyond reach. Any considerable quantity of fluid in the bladder 
should lift the uterine body entirely out of reach of the finger in the 
vagina (see Fig. 3), and give a sensation of semi-elastic or characterless 
resistance. 

Palpation of the Displaced Uterus. 

If the fundus be displaced towards the symphysis the uterus may 
be felt as a smooth pear-shaped body, three inches long, lying flat 
over, or down upon the anterior wall of the vagina with the os, at the 
smaller end, pointing backwards.* If the fundus be displaced back- 
wards the same pear-shaped body may be felt over the posterior fornix 
vaginae, lying with its larger end against or near the sacrum, and the 
smaller end turned forward, so that the os looks toward the perineum 
or the pubis. An elevation or concavity of the anterior fornix is 
caused by a backward displacement of the fundus, and is in propor- 
tion to the displacements. 

The resistance of the connective tissue at the bases of the broad 
ligaments prevents palpation of the body of the normally placed 
uterus through the lateral fornices. When, however, the fundus is 
displaced laterally, the os is turned to the opposite side, and thus sec- 
ondarily displaced, and the finger can feel the lateral uterine wall on 
the side of the displacement to be continuous, almost in a straight 
line, with the side wall of the cervix. Pressing high up in the anterior 
fornix, on either side of the median line, it loses the corpus uteri on 
one side, but can trace it for some distance toward the lateral pelvic 
wall on the other. The lateral fornix having a definite relation to 
the side of the cervix, must be shallower and wider than its opposite 
on the side towards which the fundus (or from which the cervix) is 
displaced. 

When only the cervix is displaced laterally, the os is felt turned 
toward the side of displacement so as to be entirely to one side of the 
rectum and coccyx, and the body to extend toward the median line, 
sustaining about the same relation to the direction of the pelvic axis as 
in displacement of the fundus to the opposite side, but it will reach 

* B. S. Schultze calls attention to the fact that the uterus is larger during life than 
after death owing to the amount of blood its vessels contain. During the ante-menstrual 
congestion it is still larger. 



64 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

only a little beyond its normal median position. The fornix is also 
higher and narrower on the side of the cervical displacement — unless 
altered by a growth or appreciable deposit — but the disparity of the 
lateral fornices is greater in width but less in height than that accom- 
panying primary fundal displacement. 

In extreme lateral displacement of either end of the uterus, the other 
end while turned in the opposite direction is drawn to, or over, the 
median line, so as to be mainly in the same side of the pelvis. 

In co-existent primary displacements of the fundus to one side and 
the cervix to the opposite, both are nearly equidistant from their 
median positions, but the direction of the long axis of the body of the 
uterus will be felt to be more transverse than the amount of primary 
displacement of the cervix or fundus alone would produce. The long- 
axis of the body points toward the iliac fossa rather than merely to 
one side of the pelvic axis. The fornix on the side of the cervical dis- 
placement will be very much higher and narrower than its opposite. 

Lateral displacement of the whole uterus may be recognized by the 
nearness of the cervix to one lateral pelvic wall, or by its position en- 
tirely to one side of the rectum and coccyx, accompanied by a nearly 
normal direction of the uterine axis or lateral walls, as determined by 
passing the finger-tip up into and in front of the lateral fornices. The 
fornix on the side of the displacement will be very much narrower, 
but of almost the same height as its opposite. 

While examining for lateral displacements, when the fundus lies 
back of the pelvic axis, we of course palpate its posterior surface and 
lateral edges through the posterior and lateral fornices (see Fig. 47). 
The spaces between the sides of the fundus and the pelvic walls are 
narrow and easily measured by the finger pressed well back on either 
side ; while the direction of the long axis of the uterus, and the amount 
of displacement of the os, are easily recognized by passing the finger 
straight back under the pubic arch along the anterior vaginal wall to, 
and under, the cervix. The coccyx under the finger may be used as 
a guide to the median line. 



Palpation of the Pregnant Uterus. 

The pregnant uterus assumes, even during the first three or four 
months, qualities that otherwise belong to pathological states. The 
cervix feels soft and cedematous about the external os, is down nearer 
the coccyx, and a little farther away from the inferior pubic liga- 
ment. The body is felt to recede less rapidly upward from the anterior 
vaginal wall, is softened and more bulging above the cervix,- and is 
more easily grasped bimanually. The partly filled bladder is depressed 
in the centre or on one side by the heavy fundus so as to form a broad, 
flattened fluctuating tumor. 



EXAMINATION OF THE UTERUS DURING GENERAL ANESTHESIA. 65 

Examination of the Uterus during General Anaesthesia. 

Examined in connection with the administration of an anaesthetic 
or during an unusually relaxed and insensitive state of the tissues, 
the uterus can be grasped bimanually and turned in all directions. 
By pushing the cervix back with the finger in the vagina, the uterine 
body may be brought down upon the anterior vaginal wall by the 
hand over the abdomen, so that the thickness, and the conformation 
of its anterior and lateral walls, will be readily determined. Fig. 45 
shows the relation of the fingers to the uterus. 



Fig 45. 




Bimanual Palpation of the Uterus from the Posterior Vaginal Wall (£). 

By drawing the cervix forward with one or two fingers in the vagina 
— first pressing upward in the anterior fornix, and then drawing for- 
ward under and behind the free end of the cervix — and pushing the 
fundus back with the hand above the pubes, the cervix and lower por- 
tion of the corpus can be grasped between the fingers outside and those 
in the posterior fornix as represented in Fig. 46. 

When it becomes necessary to palpate the whole posterior wall, the 

5 



Q<3 



EXAMINATION OF THE FEMALE PELVIC OBOANS. 



vaginal fingers, after the fundus lias been pushed as far back as pos- 
sible by the external hand, may press the lower, or free end of the 



7::-. 4-3. 




Bimanual Palpation of the Uterus, through the Anterior Vaginal Fornix * 

cervix, up toward the pelvic brim and thus turn the fundus into the 
hollow of the sacrum, or the recto-uterine pouch, as represented in 
Fig. 47. 

The posterior wall of the whole body will then be accessible. In 
replacing the uterus the cervix is pulled down by the ringer upon it, 
or drawn down by pressing the posterior fornix vagina? toward the 
coccyx, and then the fundus uteri pushed up toward the sacral 
promontory. The natural supports, if normal, will do the rest. 

In pushing the fundus backward into the hollow of the sacrum we 
must press just over the pubes. bo as to get under the fundus : in 
bringing the fundus forward over the anterior vaginal wall we press 
deep into the abdomen just under the umbilicus and then downward 
over the fundus. 

The uterus, as thus felt, should be smooth, hard and slightly flat- 
tened upon the anterior and posterior surfaces, without ridges or pro- 



THE ADVANTAGES OF A GENTLE TOUCH. 



67 



jections except at the upper angles or horns, where the Fallopian tubes 
and the ovarian and round ligaments pass off laterally. 



Fig. 4" 




Uterus artificially turned back against the hollow of the Sacrum, for palpation of the 
Posterior Wall (§). 

Digital Exploration of the Pelvic Roof through the Vagina. • 
By pressing with one hand firmly down over the abdominal walls 
to one side of the artificially anteverted uterus, and with the other 
upward against the anterior vaginal wall on the same side, we may 
make both hands meet with only the abdominal and vaginal walls, 
and broad ligament with its contents, between them, and palpate 
against the external hand or make the approximated fingers (external 
and internal) glide together successively over small contiguous areas 
of the pelvic roof, until the whole is explored. The skin and mucous 
membrane move with the fingers and each tissue as it slips between 
them may be recognized by its shape and position, or be traced 
throughout its course in the pelvis. In bimanual examination of the 
right side of the pelvis we should use the right hand for the vagina, 
for the left side the left hand. As a rule when the fundus uteri is low 
in the pelvis the abdominal walls should be depressed as much as 
possible ; when the fundus is high the vaginal walls should be pushed 
well up. In this way the parts are more easily reached, and are not 
much disturbed in their relations. 

The Advantages of a Gentle Touch. 
A rough finger in the vagina may press upon the tissues of the pel- 
vic roof a thousand times without recognizing them, while the touch 



68 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

of a gentle hand will locate ligaments, ureters, bloodvessels and nerves 
without difficulty. The so-called tactus eruditus is in fact nothing but 
a gentle attentive touch guided by a thorough knowledge of the 
anatomy of the parts. It may be acquired by almost any one in a 
short time, yet must remain forever out of the reach of many prac- 
titioners and specialists. 

When not to Examine. 

There are many cases in which rigidity of the abdominal walls, 
smallness of the vagina, rigidity of the perineum, abnormal sensitive- 
ness, menstruation, disease, etc., render a thorough exploration of the 
pelvic roof unendurable and frequently injurious or dangerous. When 
acute or subacute inflammatory changes exist, a knowledge of the 
location and general character of the inflammation must often suffice 
until subsequent improvement renders a thorough exploration prac- 
ticable. 

Precautions Necessary During Examination. 

It is often better to examine successive portions of the pelvis at 
different times (without anaesthesia) being careful always to desist be- 
fore irritation is produced. Unless the patient's confidence in her 
physician be well grounded, he will justly lose what she may already 
have given him in proportion as he hurts or injures her. It is also 
well to remember that, under anaesthesia, not having the patient's 
sensations to guide us, we are especially liable to manipulate tender 
or inflamed tissues until irreparable injury may be done. We should, 
therefore, when a complete exploration is necessary, examine such 
parts as we can by one or several examinations, with the patient's 
feelings to guide us in finding and avoiding tender parts ; and, then, 
on another occasion, complete the examination with the aid of an 
anaesthetic. The value of an examination is not in proportion to the 
amount, but rather to the intelligence of the manipulations. Some 
gynecologists by their attempts at thoroughness in diagnosis produce 
more irritation by their fingers than their treatment can remove; 
others with seemingly superficial examinations, yet adequate to the 
end, are able to quickly cure the patient. 

Difficulty of Differentiating Pelvic Tissues by the Touch. 

Nothing would seem easier than to approximate the fingers of the 
two hands in bimanual examinations and locate each structure as it 
comes between them. Yet when we consider that the round ligaments, 
ovarian ligaments, Fallopian tubes, ureters, inter-uretric ligaments, 
edge of the collapsed bladder, enlarged lymphatics, vaginal cicatrices, 
sacro-uterine peritoneal folds, and some aponeurotic bands about the 



HOW TO PALPATE THE OVARIES. 



69 



abdominal muscles, all give more or less the same sensation as of 
cords or ridges passing through the pelvic roof ; and that one of these 
may be over or almost parallel to another, we can appreciate the 
doubt entertained by many as to the possibility of differentiating them. 
Yet if we have in our mind the characteristics, and different positions 
and directions, of the structures as they accommodate themselves to 
the position of the fundus, and will patiently and carefully trace them 
to their attachments we may usually overcome the difficulties. 

The Starting Point in Digital Explorations of the Pelvic Roof. 

The starting point, then, of our explorations of the pelvic roof 
should be the fundus uteri which, by carrying a portion of the struct- 
ures with it in its ceaseless physiological variations, and by frequent 
pathological alterations of position, and twisting, to a greater or less 
degree, the broad ligaments upon their transverse axes, determines the 
mutual relationship of nearly all of the pelvic structures. 

How to Palpate the Ovaries. 

(1) When the Fundus is in Front of the Pelvic Axis. 
If the fundus be found in front of the pelvic axis, we may find the 
ovary (Figs. 10, 12 and 48) by introducing the index finger (two 




Positions of Ovaries as seen from the Pelvic Brim (>£). Modified from Schultze. 
a, fundus of uterus with empty bladder ; b, fundus of uterus with full bladder ; e, horn of 
uterus displaced laterally, belonging to ov 7 ; ip, infundibulo-pelvic ligament ; ov 1 , ordinary posi- 
tion of ovary ; ov 2 , ovary against the sacrum ; ov 3 , ovary over lateral vaginal fornix ; ov*, ovary 
in the pouch of Douglas ; ov G , ovary in or over the sacral pouch ; ov 7 , ovary in transverse position 
by lateral traction of uterus, c; ap, anterior superior spinous process; ps, psoas muscle. 

fingers if the index be short) to the anterior wall of the cervix, then 
passing it at right angles along the anterior edge of the base of the 



70 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

broad ligament to the pelvic wall, and pressing upward just in front 
of the attachment. 

Another way to find the ovary is to carry the ringer around the pelvic 
wall until the obturator artery is felt (see Palpation of Vessels and 
Nerves of the Pelvis, pp. 104, 107), viz., around the pubic attachments 
of the levator ani to the upper edge of the obturator muscle along 
which the artery runs, and then straight back along the side wall of 
the pelvis over the ischial spine. A little in front of the spine, and 
just anterior to the resistant base of the broad ligament, the finger 
w T hen pressed upward above the artery should touch the ovary. Un- 
usual firmness of the connective tissue and a free mobility of the organ 
may, however, prevent its easy recognition. 

Another way to find the ovary is to trace the ureter to where it 
passes under the broad ligament (see Palpation of the Ureters, p. 
78) and press up in the angle between the ureter and the pelvic 
wall. A firmly placed ureter may run so nearly under the ovary as 
to prevent the finger reaching it. If, as must often happen, there is 
doubt as to whether the ovary is over the finger, the other hand may 
be pressed into the abdominal walls on and below a line connecting 
the anterior superior spinous processes of the ilea, and about two 
and a half inches from the median line. The fingers will thus come 
against the psoas muscle passing over the pelvic brim, and if brought 
inward toward the pelvic cavity, will press into it just over the nor- 
mally located ovary, and form with the dejxressed abdominal walls a 
resistant surface against which the vaginal finger can palpate. A 
sudden complaint of being hurt, or of a sickening pain, from the pa- 
tient, will usually give us early notice that we are successful in our 
search. 

In case the uterus is drawn against or over the symphysis, the ovary 
may be found a little farther forward (Fig. 6, ov 3 ). 

Or it may be found farther back just over the outer end of the 
base of the forward leaning broad ligament. The finger then finds it 
by pressing up back instead of in front of the base of the ligament 
(Fig. 6, ov 2 ). This position of the ovary is not uncommonly found on 
one side when the fundus is farther back than normal, and the broad 
ligament of the same side is slightly shortened ; or on both sides when 
the sacro-uterine ligaments hold the middle of the uterus well back, 
and the fundus curves forward yet remains elevated from the pubes 
and anterior vaginal wall. In the first case the ovarian and infundi- 
bulo-pelvic ligaments are relaxed, in the second the upper parts of 
the broad ligaments are either slightly relaxed or shortened (since the 
corpus uteri is more directly in a line between their peripheral attach- 
ment). The ovary in either case sags down but is kept in almost its 
normal axis by normal abdominal pressure. 

Occasionally the ovary sinks downward and forward and lies against 



HOW TO PALPATE THE OVARIES. 71 

or over the obturator artery and the white line of insertion of the 
levator ani into the fascia of the obturator muscle. It can then, if 
not too tender, be easily caught between the finger and the pelvic wall 
in front of the base of the broad ligament without pushing up toward 
the pelvic brim, as is necessary in palpating the normally located 
ovary. Especially is this so on account of the flabbiness of the tis- 
sues that usually accompanies such displacement. 

When the ovary leaves the lateral pelvic wall it may often be found 
beside the cervix, just over the lateral fornix vaginae (Fig. 10, ov 3 and 
48, ov 3 ), and is detected by pressing the finger up beside the fornix with 
or without a forcing of the abdominal walls down over it by the ex- 
ternal hand. 

Another not very rare place to find the ovary is the recto-uterine 
cul-de-sac of Douglas (Fig. 48, ov 4 ). It may then be felt behind the 
posterior or lateral vaginal fornix and usually hanging over the sacro- 
uterine fold of the side from whence it came. 

Finally the ovary may be found floating or hanging back in or over 
the sacral peritoneal pouch, neither against the lateral nor posterior 
wall of the pelvis (Fig. 48, ov 6 ). It is palpated here with great diffi- 
culty per vaginam. But if enlarged and accompanied by a relaxed 
pelvic roof it may occasionally be felt somewhat as the foetal head is 
felt by ballottement. Although it does not settle upon the finger as dis- 
tinctly as does the head, yet by successive touches it is each time 
detected back from where it had receded at the previous touch. 

(2) When the Fundus lies against or near the Sacrum. 

When the fundus is in the back part of the pelvis the ovary often, 
lies back transversely on either side of the fundus in the bottom of 
the sacral peritoneal pouch (Fig. 6, ov 1 ) or against the sacrum (Fig. 
48, ov 2 ), and if the vagina be sufficiently relaxed it may be palpated 
against the posterior pelvic wall by the finger, or fingers, pressed back 
and high up on either side of the fundus. 

When in the recto-uterine pouch (or cul-de-sac of Douglas), it is felt 
under the body of the retroplaced uterus, slippery to the touch but 
confined in its motions to the space in which it is held. 

The ovary may in other cases be felt over the lateral fornix by the 
finger pushed high up beside the corpus, especially if the abdominal 
walls be depressed by the hand externally (Fig. 12, ov 5 and 10, ov 4 ). 

(3) When the Fundus is displaced toward one side of the Pelvis. 
When the fundus is drawn toward one side of the pelvis, the ovary, 

on the same side, sagging backward or forward from a relaxation of its 
ligaments, is often reached with difficulty because of the greater density 
of the contracted tissue under it. Upon the opposite side the anterior 
end is often drawn with the uterus towards the middle so that the organ 
lies somewhat transversely across the upper part of the broad liga- 
ment. Its supports being drawn a little more tense, it is more firmly 



72 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

held, and hence more easily palpated. Finally, the ovary may be 
found at the inguinal ring. 

We may thus find the ovary in eleven different positions, viz., four 
against the side wall of the pelvis— the parietal ; two about the cervix 
—the central ; two in and one above the sacral peritoneal pouches — 
the posterior ; one turned across the side of the pelvis— the transverse. 

Table of Position of Ovaries. 
I. Parietal: 

1. Normal. 

2. Displacement forward. 

3. Displacement backward. 

4. Displacement downward. 
II. Central: 

5. Over lateral vaginal fornix. 

6. In the recto-uterine or Douglas pouch. 

III. Posterior: 

7. At the bottom of the sacral pouch. 

8. Against the sacrum. 

9. Floating over the sacral pouch (changeable). 

IV. Transverse: 

10. Extending across the side of the pelvis between the 

psoas muscle and the displaced uterine horn. 
V. Extra- Abdominal or Hernial : 

11. At the inguinal ring. 

In the parietal positions the long axis of the ovary is only slightly 
changed, in the other positions it is greatly changed by a swinging of 
the organ upon the lateral attachment. 

A lump of faeces has been mistaken for an ovary in or near the recto- 
uterine cul-de-sac. This mistake, although easily made, may be 
avoided by remembering that a lump of faeces in the rectum is neither 
so smooth, tender, elusive to the touch as the ovary, nor provided with 
ligaments. A fecal mass can be displaced only with the rectal folds 
about it, but can be worked in part down into the lower rectum, can 
usually be mashed by moderate pressure and without pain, and is apt 
to be accompanied by one or more lumps above or below it, along the 
course of the viscus. 

Palpation of the Ovarian Ligament. 

The chief value of palpation of the ovarian ligament lies in the fact 
that it leads to the anterior or inner end of the ovary, and that the 
Fallopian tube may usually be found floating above it, or not far off. 
It is of firm fibrous structure, short and quite inelastic. It feels larger, 



THE INFUNDIBULO-PELVIC LIGAMENT. 73 

harder, and more resistant than the round ligament, Fallopian tube, or 
ureter, to bimanual palpation. 

When the fundus is forward we may, by moving the bimanually 
approximated fingers of both hands slowly forward beside the uterus, 
feel the ligament, as it is pulled forward, suddenly slip from the grasp 
back to its position, and away from the fingers, with a jerk or snap 
that is so decided as to be almost characteristic. This almost trans- 
verse direction of the ligament with the fundus forward shows the 
ovary to be normally forward (Fig. 48, ov 1 ), and but little, if at all, out 
of place. A more diagonal direction of the ligament indicates a sag- 
ging back of the ovary (Fig. 6, ov 2 ), or a leaning forward of the fundus 
uteri (Fig. 6, ov 3 ). 

When the ovary lies beside the cervix the ligament, although not 
easily accessible, may be felt passing along beside the uterus from the 
fundus to the cervix, whether the fundus be forward (Fig. 48, ov 3 , and 
Fig. 10, ov 3 ), or backward (Fig. 10, ov 41 ). When the ovary lies in 
the recto-uteriue pouch the ligament will curve around beside the 
uterus toward the fundus, and may be felt passing over the correspond- 
ing recto-uterine peritoneal fold (Fig. 48, ov 4 ). When the fundus is 
back in the pouch of Douglas the ligament, although relaxed, may be 
palpated against the uterus over it or the sacro-uterine ligament beside 
it. When the fundus and ovary lie against the sacrum the ligament 
may be felt connecting them by pressing the finger back against the 
sacrum beside the fundus. When the ovary floats over the posterior 
lateral peritoneal pouch the ligament can seldom be detected unless 
the ovary can be pressed back against the sacrum or pulled forward 
with the fundus and palpated bimanually beside the corpus uteri. It 
then goes from ov e , Fig. 48, to positions corresponding to that repre- 
sented on the opposite side by ov 2 and ov 3 . 

The Infundibulo- Pelvic Ligament. 

The infundibulo-pelvic ligament may in some instances be palpated. 
When the ovary lies at the side of the pelvis the fimbriated extremity 
of the Fallopian tube serves as a guide to it, and can occasionally be 
traced to it, and recognized bimanually as a ribbon-like fold extend- 
ing to the belly of the psoas muscle at the side of the pelvic brim. 
When the ovary lies in the pouch of Douglas it may be felt passing 
from the ovary over the sacro-uterine ligament along with the larger, 
harder, but more relaxed ovarian ligament. When the ovary is against 
the sacrum, or low in the posterior lateral peritoneal pouch, the infun- 
dibulo-pelvic ligament may occasionally be palpated against the pelvic 
wall by hooking the finger over it just external to the ovary. When 
both this and the ovarian ligament proper are traced to or from the 
ovary, the place, position and relation of that organ is determined, and 



74 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

the condition of the upper and outer portion of the broad ligaments 
may be inferred, especially when taken in connection with the condi- 
tion of the round ligament. 

Palpation of the Round Ligament. 

As the round ligament is high up in the pelvic roof, and composed 
of muscular tissue, it offers, unless contracted or unusually tense, only 
an indistinct sensation of resistance to the finger in the vagina. 
Bimanually, however, it is easily found running almost straight out- 
ward from under the uterine horn, and assuming a constantly increas- 
ing curve forward until behind the internal inguinal ring, when it 
passes almost directly forward into it. It feels somewhat larger when 
contracted than when relaxed, seldom quite as large as the ovarian 
ligament, and does not slip with such a decided snap through the 
fingers and out of the way. When relaxed it sags outward and forms 
a larger curve, thus tending to get out of reach of the vaginal finger 
(see Fig. 6). 

On account of the frequent difficulty experienced in differentiating 
it from the structures about it, we will briefly indicate how to pick it 
up bimanually and trace it from the internal abdominal ring to the 
uterine horn. The internal abdominal ring is at the pelvic brim about 
as far from the pubic arch or vaginal entrance as the index finger can 
conveniently reach, and as high or a little higher than the natural 
resistance of the tissues will allow it to go. If we insert the index 
finger of our right hand into the vagina, and slip it upon the posterior 
surface of the right pubic bone along the upper edge or pubic attach- 
ment of the levator ani, we will come upon the groove of the white 
line or reflection of obturator fascia (Fig. 17) forming, where it strikes 
the bone, a distinct depression or fossa. Above and just external to 
this, the round ligament passes into the ring ; and if it be contracted 
and firm may be felt as a ridge passing backward from the ring by 
pressing up the point of the finger to the pelvic brim and then veering- 
it outward as far as possible. But on account of the sensitiveness of 
the parts thereabout, the resistance of the displaced tissues and the 
mobility of the ligament, it is advisable to depress the pelvic roof and 
inguinal ring toward the finger. Accordingly we press with the out- 
side hand down over Poupart's ligament from two to two and a half 
inches (about four fingers' breadth) from the pubic spine until the liga- 
ment comes within reach of the finger inside. The ring may some- 
times be recognized by the pulsations of the epigastric artery under 
it and extending up the abdominal wall, but most usually by the 
round ligament itself as palpated against the depressed tissues. The 
most satisfactory way is to thus approximate the fingers of the two 
hands, and move them sideways until the ligament slips between 
them, and then trace it forward and around its curve, always moving 



PALPATION OF THE ROUND LIGAMENT. 



<D 



the fingers at right angles to it. The amount of tension and degree of 
curvature of its outer end will usually enable us to calculate the rest 
of its course to the uterine horn. When relaxed it seems farther from 
the symphysis and is not so readily made to slip through the bimanual 
grip. Fig. 6 shows the difference in the curves of the contracted and 
relaxed ligaments. They may sometimes be made tense, and palpated 
through a voluminous vagina by hooking the lower end of the cervix 
forward with the index finger, thus prying back the fundus upon the 



Fig. 49. 




Artificial Tension of the Round Ligament, using the Sacro-uterine Attachment as a Fulcrum {%). 
r, round ligaments ; su, sacro-uterine ligaments; u, uterus. 



sacro-uterine attachments as a fulcrum and then pressing the middle 
finger toward the side of the pelvic roof. (See Fig. 49.) The external 
hand may be made to increase the tension by pressing into the ab- 
dominal walls just above the pubes and then upward under and against 
the fundus. When the ligaments are contracted so as to be firmer than 
the sacro-uterine ligaments, the fundus in the above-mentioned mani- 
pulation becomes the fulcrum and the whole lower end of the uterus, 



76 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



instead of only the external os, will be pulled toward the vaginal out- 
let. Contraction of the round ligament may be thus recognized, and 
also by several other signs. The fundus lies behind, or over, and very 
near the pubes (Fig. 50) and presents a resistance to upward pressure 
behind the pubic arch much greater than its weight, yet one which 
readily yields to steady pressure. The upper portion of the broad 
ligament is rendered tense as indicated by the firmness of the pelvic 
roof or either side of the fundus behind the body of the pubis, and 
sometimes by a ridge corresponding to the course of the ligament. 



Fig. 50. 




Position of Uterus produced by contraction of the Round Ligaments (J). Fundus behind 
pubes. (Case 21, office record of 1886, Mrs. W.) 

When the contraction is extreme even the base of the broad ligament 
on either side of the internal os is felt to be drawn into a characteristic 
prominent ridge. 

Contraction of only one ligament draws the fundus and body 
toward the same side, and points the external os toward the opposite 
side of the pelvis. 

When the fundus lies against the hollow of the sacrum the round 
ligament may be traced bimanually from the internal abdominal ring 
almost straight back to where it passes over the twisted broad liga- 
ment (Fig. 6, br and brc) ; and occasionally may be traced forward from 
the uterine horn near the sacrum to the base of the broad ligament. 



PALPATION OF THE FALLOPIAN TUBES. 77 

The ovarian, round, and infundibulo-pelvic ligaments, ureters, arteries, Fallopian 
tubes, etc , are larger in life than in death, on account of the blood in them, and seem 
still larger to the vaginal touch from being covered by the vagina and layers of peri- 
toneum or connective tissue. Contraction also increases their apparent size to the 
touch. 

Palpation of the Fallopian Tubes. 

When the fundus uteri is forward behind the pubes and the ab- 
dominal walls lax, the Fallopian tubes may be quite easily felt bi- 
manually. From their uterine ends, which are then over the lateral 
edges of the empty bladder, they pursue a slightly serpentine course 
over the paravesical pouches to the sides of the pelvis, where they 
curve backward toward the ovary (Fig. 12, ov l ). Bimanually they are 
felt to be soft flabby cords, with apparently several twists or zigzags in 
them, which are characteristic. They yield to forward or backward 
traction (bimanually) without that feeling of elasticity or firm resist- 
ance which causes the round and ovarian ligaments to return rapidly 
to the position from which they are drawn, but with a characteristic 
drag upon their broad ligament attachment. We may differentiate 
them from the edge of the bladder by tracing them laterally or pos- 
teriorly around a long curve whose convexity is forward, instead of a 
short curve whose convexity is backward, by their greatest resistance 
to forward traction, instead of backward, by their entire independence 
of the folds of the bladder, and by their attachments to the fundus 
uteri. 

When the fundus is not, or cannot, be pressed forward behind the 
pubes, the tubes are farther removed from the abdominal wall mova- 
ble, flabby, and sometimes surrounded by intestinal loops. Such is 
probably the most natural position. If the uterine horn and position 
of the ovary has been found, we may calculate that the tubes will 
pass in a curve between it, a little in front of the shorter and straighter 
ovarian ligaments. 

By placing two fingers in the vagina, one upon each side of the 
cervix, and pressing as high up as possible, the middle finger may 
often be approximated to those externally pressed down into the 
abdominal walls and then all pulled forward together. The ovarian 
and round ligament, and then the Fallopian tube, may thus be made 
to slip between the fingers, like three cords of progressively diminish- 
ing size and elasticity. Even when these structures lie directly over 
each other (or together), the shortness and rigidity of the ovarian 
ligament causes it to become tense and slip between the fingers first, 
while the flabbiness of the tubes usually permits them to be drawn 
forward so as to escape last. 

If the ovary and fundus uteri be situated posteriorly, so will ordi- 
narily the Fallopian tube (Fig. 12, ov 2 ), and may often be palpated 
against the sacrum. If the fundus be forward and the ovary back. 



78 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

(Fig. 12, ov 3 ), or the fundus back and the ovary forward beside the 
cervix (Fig. 12, ov 5 ), the tube will pass backward or forward from the 
uterine horn toward the ovary, either almost directly over the ovarian 
ligament or a little external to it. If the fundus be forward or central, 
and the tube extend into one of the sacral peritoneal pouches, its 
fimbriated end may sometimes be pushed back upon the sacrum 
where its irregular contour can be easily appreciated. Whether the 
fundus be forward or backward, the fimbriated extremity, or a loop 
of the Fallopian tube, may be felt hanging over a sacro-uterine 
fold into the pouch of Douglas. Its length, limpness, and slightly 
irregular or undulating course over the sacro-uterine ligament, will 
distinguish it from the ovarian ligament. By bringing the fundus 
well forward, and then dragging the tube forward bimanually, it may 
in some cases be brought anteriorly from the sacro-uterine into the 
para-vesical pouch, and there palpated. 

In a general way it may be said, that if the ovarian ligament be 
first found, the tube being longer and looser, will be found in front of 
it when the fundus uteri and broad ligament are forward, so as to 
receive the abdominal pressure on their posterior surfaces ; behind or 
above it when the parts are back so as to receive the abdominal pres- 
sure on their anterior surfaces ; or floating over it before or behind, 
indifferently or alternately, when the pressure is parallel to the long 
axis of the uterus. 

Of all the normal tissues of the pelvic roof which may be said to 
be always or almost always palpable, the normal Fallopian tubes are 
probably the most difficult to detect. When hardened or enlarged, 
however, they are proportionately easy. The following table of the 
positions in which the non-adherent tube is most frequently found, 
may be useful to the student : 

1. Normal. 

2. In or over the para-vesical pouch. 

3. Upon the posterior surface of the broad ligament. 

4. In or over the sacral pouch. 

5. In the retro-uterine pouch. 

Palpation of the Ureters. 

When surrounded by healthy tissue the ureters, at their lower or 
pelvic portions, are among the most readily and uniformly palpable 
of the smaller tissues of the pelvic roof— much more so than the 
ovary, the ovarian and round ligaments, Fallopian tube, arteries, 
nerves, etc. 

In seventy-five consecutive gynecological cases in office practice the ureters were 
examined by simple vaginal indagation, with the following results: At least one 
ureter was recognized in every patient: both were felt in all but eight, i.e., 142 of the 



HOW TO FIND THE URETERS WITH CERVIX IN NORMAL POSITION. 79 

150 ureters. Of the eight not felt, two belonged to the right, and six to the left side. 
The causes of failure to recognize them were chiefly tenderness, induration, contrac- 
tion, cicatrization and tension of the vaginal walls or contiguous connective tissue. 
In three of the cases the os was drawn back from 3£ to 4 inches from the inferior 
pubic ligament; in four cases it was turned forward by backward displacement of the 
fundus; in one case the ureter was displaced by a tumor growing from the uterus. 
The ureters are easily felt during pregnancy, for several reasons: such as increased 
tension produced by the sinking of the uterus and broad ligament upon them ; soften- 
ing of hard tissues under them ; apparent increase in their volume due to the serous 
infiltration and vascular turgescence in and about them ; and later, the presence of an 
enlarged uterus against which to palpate them. 

How to find the Ureters ivith Cervix in Normal Position. 

Having touched the anterior wall of the cervix, the index finger is 
brought forward along the anterior vaginal wall, from an inch to an 
inch and a half, until the inter-uretric ligament is felt passing across. 

Fig. 51. 




Positions of Ureters { x / 3 ). Schematic. 
Those on the right side are relaxed ; those on the left are somewhat tense, a, belongs with 
cervix displaced backward; b, belongs with cervix in about normal position; c, to cervix dis- 
placed forward and upward with fundus turned into the hollow of the sacrum (retroversion). 
o 1 , ft 1 , c 1 , same as a, b, c, but relaxed. 

If this be not felt the place where the smooth soft upper end of the 
anterior vaginal wall merges into the rougher and firmer lower portion 
indicates about where it lies. From the end of the inter-uretric liga- 
ment, viz., a point about half an inch to the side of the median line 
the ureter is felt to run as an elastic cord, seemingly the size of a small 
goose quill, almost straight towards the ischial spine, where it curves 
up under and behind the broad ligament. The finger end pressed 
gently (sometimes firmly) up into the yielding parametric tissue 
beside the cervix, and hooked or drawn forwards toward the pubic 



80 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

bone of the same side, will readily feel the ureter slip over it, marking 
the boundary between the softer parametrium and the harder periph- 
eral zone of fat-containing connective tissue. Sometimes by placing 
the side of the finger flat along the course of the ureter we may feel 
quite a stretch of it at once. The pulsation of the middle vesical 
artery, which lies near it, and is often large enough and near enough 
to the vaginal mucous membrane to be felt at the same time, may, by 
the hasty finger, be mistaken for it. Fig. 51, b and ft 1 , shows approxi- 
mately the position of the ureters when the cervix is in a normal 
position. 

Palpation of the Ureters when the Cervix is Displaced Backward. 

"When the cervix is drawn far back in the pelvis, the base of the 
trigone usually follows the cervix, and allows the ureter to retract 
into a quite firm cord easily felt (Fig. 51, a and a 1 ). AVhen, however, 
the trigone does not follow back the cervix, the ureter drawn upon by 
the retroposed base of the broad ligament, is stretched and attenu- 
ated, and having a stretched firm parametric tissue behind it cannot 
always be as readily recognized. By pressing up along the lateral 
edges of the uterine body (which in this case is generally turned 
forward) the lower end of the ureter may be got between the finger 
tip and the uterus as if it were a small cord, and then be traced 
laterally. 

Palpation of the Ureter when the Cervix is Displaced Forwards. 

When the cervix is displaced forward, the lower edge of the broad 
ligament, drawn forward with the cervix, usually relaxes the ureter, 
and permits it and the base of the trigone to sag forwards over the 
relaxed vaginal walls so as not to be felt in its ordinary place (Fig. 51, 
c and c 1 ). Its flabby condition may also prevent it being recognized 
when pressed upon by the finger. In such case it may be hooked 
forward toward the pubes and rendered tense, or hooked against the 
pubes, under the bladder, and palpated upon the inner surface of the 
anterior pelvic wall ; then traced upon the pelvic walls around to the 
base of the broad ligament, and from there back across the trigone to 
the opposite side. 

The bimanual examination is seldom necessary for finding the 
ureter, although it is very easily palpated in this way. On account 
of being felt first and easiest it is liable to be mistaken for other tis- 
sues sought, but other tissues, except an artery or a cicatrix, are sel- 
dom mistaken for it. In bimanual palpation of the other structures 
of the pelvic roof it is desirable, in order not to disturb their relations, 
to press the finger in the vagina well up into the pelvic roof where 



PALPATION OF THE BROAD LIGAMENTS. 81 

they lie, while in that of the ureter it is better to press the hand over 
the abdomen well down into the pelvic cavity near where it lies. 

Differentiation. 

The ureters are easily known from other structures of the pelvic 
roof by being found so near to the vaginal walls ; by being traceable 
forward to and across the trigone instead of to a uterine horn, as the 
round and ovarian ligaments and Fallopian tube ; by passing under 
the base of the broad ligament instead of over it, as do the round and 
ovarian ligaments, and Fallopian tube ; and by their direction, which 
is normally more nearly backward than these other structures. In a 
forward position of the cervix with a turning back of the fundus the 
ureters are displaced forward, and often palpable against the pubis, 
while the other structures of the pelvic roof are displaced backward, 
and sometimes palpable against the sacrum. 

Palpation of the Broad Ligaments. 

(1) The Upper or Uterine Portions. 

The absence of intestinal loops in the para-vesical peritoneal pouches 
while the patient is in the dorsal position indicates that the upper parts 
of the broad ligaments are forward; while the presence of any con- 
siderable amount of intestine felt anteriorly and causing a bulging- 
down of the pelvic roof on either side indicates that the upper por- 
tions are either relaxed or forced back, or both. 

As the upper portions of the ligaments are not easily felt, we must 
often, in order to determine their position and condition more defi- 
nitely, locate their internal or changeable uterine attachments, and 
the tissues which pass through or over them to their external fixed 
ends. 

When the fundus is forward while the cervix, the ovary and its liga- 
ment, the Fallopian tube, and the uterine end of. the round ligament 
are in their normal positions, so must be the broad ligament. It thus 
receives the greatest amount of abdominal pressure upon its posterior 
surface. When the fundus is high out of reach above the vesico- 
vaginal septum, the ovary beside a normally located cervix, the Fal- 
lopian tube curving back or over it, and the round ligament extending 
from the abdominal ring in a slight curve to one side of, or back of, 
the pelvic axis, the broad ligament is relaxed and receives the prin- 
cipal abdominal pressure almost in the direction of the uterine axis. 
When, however, the cervix has settled down within half an inch or 
so of the coccyx, but the ovary and the tube normal in position and 
the round ligament firm, the upper portion although necessarily carried 
down with the depressed uterus is stretched rather than relaxed. 
When the whole uterus and its appendages are pressed back against 

6 



82 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

or near the sacrum, and the round ligament lax, and the uterus 
straight, the upper portion of the broad ligament must be relaxed 
and receive the abdominal pressure mainly upon its anterior sur- 
face. 

Lateral displacement of the fundus with contraction of the upper 
part of the ligament is recognized by a hardening beside the horn 
holding it with more or less rigidity ; lateral displacement with relaxa- 
tion is known by the flabbiness beside the horn and the sagging back 
of the ovary and tube. Tension of the ligament opposite the dis- 
placed fundus is known by the tension and transverse direction of the 
ovarian ligament drawing the uterine end of the ovary away from the 
pelvic wall, the more diagonal direction of the round ligament bring- 
ing it nearer the vaginal entrance, and the ease of recognition of the 
appendices. A general tension of the ligament is in such cases recog- 
nizable unless the vaginal tube be narrow. 

When the cervix is forward and the fundus in the hollow of the 
sacrum, the broad ligament is twisted upon its transverse axis and 
receives the abdominal pressure entirely upon its anterior surface. 
If, at the same time, the ovary and its ligament be against the sacrum 
the upper uterine portion must be relaxed or stretched. When the 
fundus is drawn or pressed back against the sacrum and the os for- 
ward, and the broad ligaments at the same time held forward, the 
ovarian ligament will pass forward to the ovary, which will be beside 
the cervix (Fig. 12, ov b ) or floating near it (Fig. 6, ov 1 ), and the Fallo- 
pian tube over or near it. The round ligament will generally be 
somewhat tense, and pass almost straight from the abdominal ring to 
the fundus (Fig. 6, brc). 

(2) The Bases, or Cervical Portions. 

The base of the broad ligament may usually be directly palpated 
either through the vagina or rectum. Ordinarily the finger can feel 
an indefinite ridge on either side of the cervix extending laterally. 
When .the base is quite firm and resistant, or a little stretched, two 
ridges may even be felt corresponding to the fibres running from the 
cervix to the anterior and to the posterior peritoneal layers. When 
drawn upon so as to become unusually tense these two fibrous ridges 
are drawn into one layer, but a much more definite and prominent 
one. With relaxation of the base of the ligament the ridge at the side 
of the cervix ceases to be distinctly felt. 

But as palpation for any distance from the cervix is occasionally 
rendered unsatisfactory by a small vagina or the general firmness of 
the supra-vaginal tissue, we may find it convenient to calculate the 
condition of the base of the broad ligament from the position and 
mobility of the cervix and ureters. When the cervix is down near 
the coccyx or forward near the vaginal entrance the base of the liga- 
ment, as already intimated, must be stretched or relaxed. In the first 



VAGINAL PALPATION OF THE SACROUTERINE LIGAMENTS. 83 

case, if stretched, it will be easily felt, if relaxed, it will not. In the 
second case its lower edge will be turned forward and upward and 
will afford little or no characteristic resistance. 

Pressing the cervix from side to side, the amount of resistance en- 
countered informs us of the amount of relaxation, stretching or 
rigidity of this portion of the ligament. The relaxed ligament affords 
practically no resistance to lateral displacement of the cervix, and 
allows the cervix to settle slowly back towards the median line ; the 
normal ligament affords but little resistance, and admits of a consid- 
erable displacement, yet by its elasticity brings the cervix back into 
position immediately and rapidly ; the stretched ligament affords 
considerable elastic resistance, and admits of only slight lateral dis- 
placement ; while the rigid ligament allows of little or no displace- 
ment without such violence as to cause the patient great discomfort. 

When the base of the broad ligament is much relaxed the ureter is 
no longer held normally taut, but becomes more or less flabby, runs a 
little nearer the pubis, and may be hooked forward near to the anterior 
pelvic wall. When the base of the ligament is turned forward and 
upward as in twisting of the whole ligament from a backward ver- 
sion of the uterus, the ureter may be dragged forward so as to be 
easily palpated against the anterior and lateral pelvic wall. When 
the bases of both broad ligaments are relaxed and turned forwards 
the inter-uretric ligament and the trigone are found considerably 
nearer the pubes than otherwise (see Fig. 51, c 1 ). 

With relaxation of the base of only one ligament the cervix, when 
it sinks down or moves forward, must, of course, swing slightly toward 
the opposite side since the normal ligament only allows the cervix to 
swing upon its attachment to the pelvic wall as a radius. The direc- 
tions already given for determining the position of the corpus and 
cervix uteri when laterally displaced, will also aid in the diagnosis 
of contraction and stretching of one ligament at a time. 

Vaginal Palpation of the Sacro-uterine Ligaments. 

Two ringers carried high up in the posterior fornix vaginas can 
usually feel the semi-circular folds of the sacro-uterine ligament ex- 
tending outward, backward and upward. If contracted they will 
pass straight towards their sacral attachments, and form a well-defined 
V whose angle is at the cervix. If they cannot be thus reached the 
cervix may be hooked forward by the finger as represented in Fig. 49, 
in artificial tension of the round ligaments, except that the middle 
finger is kept behind the cervix and in the posterior fornix, against 
the ligaments (s u) stretched so as to assume the V-shape (see Fig. 
52, *). In case the cervix be forward so as to stretch them, and the 
fundus turned back upon or between them, they will often be so 



84 EXAMINATION OF THE FEMALE PELVIC OEGANS. 

attenuated, and hug the sides of the corpus uteri so closely, as not to 
be felt. The finger may then, by pressing high up in the posterior 
fornix, tilt the body of the uterus forward and upward, and reach over 
one of the folds from which the uterus has been lifted. 

The position and mobility of the cervix is sometimes of great value 
in estimating the condition of these ligaments, since they are some- 
times difficult to reach. When they are retracted the upper part of 
the cervix is drawn up toward the second sacral vertebra and the os, 
if no flexion exist, will be turned backward facing the lower sacral 

Fig. 52. 



dcrvuo \^-—^^^—^ 

Uterine Torsion produced by Contraction of the Sacro-uterine Ligament of one Side (1, 2, 3). 
Straightening of sacro-uterine ligament by traction (4) causing them to assume a V-shape {\Q. 

vertebra?. The external os may then be from three to three and a half 
inches from the inferior pubic ligament and more than an inch above 
the coccyx (Fig. 53). When the retraction is permanent the os and 
lower end of the cervix often points forward more than natural, but 
remains in the back part of the pelvis. 

The distance of the cervix from the coccyx and inferior pubic liga- 
ment is almost in proportion to the amount of shortening. The fun- 
dus is at the same time pressed downward by the abdominal pressure 
acting more effectively on the upper longer arm of the uterine lever, 
so that the body is easily felt through the anterior vaginal wall. 
When the contracted round ligaments draw the fundus down near the 
symphysis the position of the uterus seems the same to the inexperi- 
enced or hasty finger ; but a measurement will show that although 
the os is turned backward the end of the cervix is not drawn up from 
the coccyx and is but little farther from the inferior pubic ligament 
than normal (see Fig. 50) and the internal os is drawn toward instead 
of from the subpubic ligament, as in contraction of the sacro-uterine 



VAGINAL PALPATION OF THE SACRO-UTERINE LIGAMENTS. 85 



folds (compare Figs. 50 and 53). The resistance to upward pressure 
by the fundus so noticeable in contraction of the normal ligaments 
(see Palpation of Round Ligaments, p. 69) will be absent and the uterus 
will have its fulcrum at the attachments of the sacro-uterine ligaments 
(Fig. 49) instead of at the fundus. The length and the resistance of 
the latter may also be tested bimanually by hooking the vaginal finger 
behind the lower end of the cervix, and bringing the external hand 
down over and behind the fundus. By thus pulling the fundus and 
cervix forward simultaneously, we draw directly upon the ligaments. 

Fig. 53. 




Position of Uterus produced by contraction of the Sacro-uterine Ligaments (%)■ 
Compare with Fig. 50. (Case 118, office record of 1886, Mrs, McC). 

When they are normal or relaxed the vaginal finger will sometimes 
reach up between their cervical attachment so as to pull the cervix 
forward toward the symphysis. In nullipara they lose little by little 
their extensibility, and as age advances become firm and compara- 
tively inelastic. 

The presence of the external os down near the coccyx, or forward 
near the pubes, is proof of relaxation or stretching of their substance. 
Direct palpation behind and on either side of the cervix is then easy 
and affords more definite evidence of the condition. 

Contraction of only one of the ligaments is attended by displace- 
ment of the cervix backward, upward and toward the same side. In 



86 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

addition to this the cervix, as B. S. Schultze has taught us,* is twisted 
so that the side toward the contraction is turned forward, i.e., the 'pos- 
terior surface of the cervix faces toward the direction of the contraction, 
and does so in proportion to the contraction. Fig. 52, 1 , 2 , 3 , shows 
the direction of the transverse slit of the os with the different degrees 
of contraction. The uterus if pressed in all directions will be felt to 
move upon the contracted ligament as upon a pivot, in a manner that 
is striking and characteristic. 

Palpation of the Pubo- Vesico- Uterine Ligament. 

The firm connective tissue union between the bladder and vagina, 
and bladder and uterus, and the attachments of the bladder and vagina 
to the pelvic fascia behind the pubes, constituting the pubo-vesico- 
nterine ligament, form a large and important part of the pelvic roof. 
In the dorsal position the finger on either side of the urethra may be 
brought up without interference of the soft parts, against the inferior 
pubic ligament and carried straight back to the cervix, along the an- 
terior vaginal wall a distance of about two and a half inches. 

With the cervix at or in front of its normal position a want of retrac- 
tility is generally revealed by a transverse fold extending across under 
the base of the trigone, and along the course of the ureters, forming a 
crescent whose convexity is forward. If the relaxation be in the 
parametrium the anterior vaginal wall will be flat and firm under the 
trigone, but there will be a furrow around the cervix. The relaxation 
is then due to the forward position of the cervix, especially its lower 
portion, and is due to the altered axis of the uterus. An unusual dis- 
tance of the base of the trigone and inferior ends of the ureters from 
the cervix would be diagnostic of true relaxation or lengthening of the 
parametric end. If the relaxation be in the peripheral portion the fold 
will consist more of a depression about the trigone and urethra and 
pubic arch instead of a raising of the parametrium. An unusual 
flabbiness is also found in the latter class of cases, permitting the 
finger to press high up behind the pubes before encountering much 
resistance. Temporary vaginal folds are produced by the emptying 
of an overfilled bladder, changes in the position of the body, etc., 
chiefly by their effect upon the position of the cervix. 

When the cervix is much farther back than normal the pubo-uterine 
ligament must be either stretched or relaxed. If stretched it will be 
flat, firm and smooth ; if relaxed it will be soft and somewhat convex. 
The base of the trigone will indicate by its increased distance from the 
cervix, the pubes, or both whether the stretching or relaxation be in 
the peripheral or deeper portion of the whole ligament. 

* Die Pathologie and Therapie der Lageveraenderungen derGebaermutter. Berlin, 
1881. 






PALPATION OF THE PUBO-VESICO-UTERINE LIGAMENT. 87 

When the ligament is overdistendecl or displaced downward by 
pressure or by a loss of integrity, it becomes convex instead of flat to 
the touch. If the parametric portion alone be distended and bulging 
down, we will notice an increase in the distance from the vaginal por- 
tion of the cervix to the trigone and to the pubes, and be obliged to 
press deep into the parametrium before reaching the upper end of the 
cervix. The convexity commences at the cervix. Distension of the 
parametric portion to an extreme degree, accompanied by a separation 
of the cervix and bladder, is recognized by the pressure of intestinal 
loops, and borborygmus, over the upper bulging end of the anterior 
vaginal wall beyond the base of the trigone and between the ureters. 
Pressure high up in the lateral fornices, or a bimanual examination, 
shows the whole uterus to be pressed back behind the pelvic axis. The 
prolapsed parts may be felt at the vaginal entrance when standing, yet 
can be made to sink back deep into the vagina when the dorsal de- 
cubitus is assumed. In such case the lower end of the ureters, base of 
the trigone, bladder, and the upper end of the urethra are displaced 
forward toward the symphysis but not much downward. 

If, however, the anterior or peripheral end of the ligament be relaxed 
or injured so as to be displaced downward, the last-mentioned struct- 
ures will swing around under the pubic arch into the vaginal entrance. 
Intestinal borborygmus or resonance will not be felt as the bladder 
must come down in front of the bowel, nor can the prolapsed parts 
readily sink back deep into the vagina. There will also be a short 
stretch of firm parametric tissue (flat or concave) in front of the cervix, 
through which the upper end of the cervix can be felt. 

If the displacement and relaxation involve the whole pubo-uterine 
ligament the urethra, trigone, bladder and parametric portion will all 
be felt to be bulging down together from the cervix to the pubic arch. 

If the chief relaxation and displacement be laterally in the para- 
vesical region the anterior vaginal grooves (or sulci) instead of being 
elevated as high or higher than the centre of the anterior vaginal wall 
will be depressed and rounded off, apparently narrowing the wall. 

Contraction of the pubo-uterine ligament draws the cervix forward, 
and renders the anterior vaginal wall firm and rough. It sometimes 
makes the anterior lip of the cervix seem shorter than natural, and 
may produce a distinct fraenum extending from the anterior lip into 
the vaginal wall, not unlike that felt in front of the atrophied senile 
cervix. (See Senile Cervix, p. 60.) If the cervix be turned forward 
by the displaced fundus the ligament may be flabby to the touch, and 
will only develop the above qualities when an attempt at replacement 
is made. The replacement of the cervix accompanied by palpation 
of the base of the trigone will show by its position whether one end 
only, or the whole ligament, is contracted. 

Contraction laterally in the para- vesical region is apt to be unilateral, 



88 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

and draws the vaginal groove or sulcus upward and outward, making 
it deeper and narrower, and unless the cervix be also drawn to the 
same side, gives it a curve whose concavity is inward. This is easily 
recognized by the finger tip in passing from the urethral notch to the 
lateral fornix. 

Palpation of the Vagina. 

During vaginal palpation of the pelvic organs it is necessary to take 
into consideration the natural characteristics and varying conditions 
of the vagina itself. In the parous woman the vagina is often suffi- 
ciently voluminous and relaxed to offer "no obstacle to the explora- 
tion of the whole pelvic interior, while in the nulliparous or virgin 
state it sometimes lies close around the finger like an elastic tube, pre- 
venting the recognition of anything except the cervix uteri. Thus 
we have a vaginal resistance or elasticity to be differentiated and sub- 
tracted from that of the other tissues, and which gives rise to different 
sensations according to the distance of the tissues, and the amount of 
force used in reaching and palpating them. 

Although the character of vaginal resistance is usually of a slightly 
elastic nature, sometimes the vaginal walls act as an inelastic bag-like 
check to the progress of the finger, which may be compared to the check 
experienced by the extended fingers in putting on a short, loose mitten. 
This check may be so sudden or complete, especially to lateral upward 
pressure into the anterior vaginal grooves, as to lead to the belief of 
having encountered a boggy tumor. Continuous steady pressure in 
such cases gradually draws the vagina toward the part to be exam- 
ined, overcomes the interference, and gives time and opportunity to 
detect the characteristic sensations afforded by contact with each tissue 
as it is reached. (Resistance of the submucous or supravaginal tissues 
has other characteristics, viz.. that of a stretched cord or band, as an 
ureter, an artery, a cicatrix, a round or ovarian ligament: of a flat or 
convex surface, as the body of the uterus, base of a broad ligament, 
pelvic wall, the trigone, levator ani muscle, etc. ; of a lump or ridge. 
as the ovary, rectum, a fecal mass, a contracted muscle, the uterus, 
etc. ; or of a varying character, as when passing from the peripheral 
connective tissue into the parametrium, from the flat pubo-uterine 
ligament to the tissue upon the side, or from the base of the broad 
ligament under the sacral peritoneal pouches, etc.) 

Resistance in the fornices. except in a very short vagina, depends 
upon the firmness of the overlying connective tissue to which it is 
intimately attached, and affords some knowledge of the firmness or 
tension of the ligaments inserted over and into them. To the gentle 
touch, they should feel smooth and firm. As the finger glides forward 
the anterior fornix, the anterior vaginal wall feels smooth, flat 
and elastic for about an inch. Here in passing from the soft elastic 



PALPATION OF THE VAGINA. 89 

parametrium across the inter-uretric ligament and under the trigone, a 
sensation of increased firmness and roughness is experienced. Towards 
the pubes this roughness is developed into distinct transverse rugae 
which cover the urethra to the meatus. Frequently one or two ruga? 
extend under the inferior pubic ligament across the urethral notches 
where the mucous membrane is closely adherent. At the centre of the 
urethral fossae and back along the anterior vaginal grooves, or lateral 
edges of the pubo-uterine ligament, to the lateral fornices, the mucous 
membrane becomes smooth and concave to the touch. 

These rugae are caused by the contraction or retraction of the fibrous 
tissue of the vaginal wall, and render it practically shorter, thicker 
and firmer, without destroying its distensibility. When the nullipa- 
rous cervix has been displaced forward for a long time the rugae become 
large and firmer, shortening and straightening the vaginal wall and 
taking the place of the transverse fold that results from such tempo- 
rary displacement. Such shortening finally may prevent replacement 
of the cervix, and is generally an evidence of a long continuance of 
the malposition. We may distinguish physiological retraction from 
atrophy or pathological contraction by practicing long-continued mod- 
erate pressure upon the cervix. In the first condition the cervix will 
draw out the vaginal wall and go back to place, in the second it will 
not. In case of atrophy the rugae are either small or absent. 

Pathological changes are apt to be accompanied by more hardening 
of the deeper tissues and to be more pronounced upon one side, or over 
a more limited area, or along a ridge. Contraction of the anterior 
vaginal wall tends to bring forward the centre of the projecting trans- 
verse crescentic fold found in forward displacements of the cervix, 
until its posterior or concave edge is at or in front of the base of the 
trigone, and thus increases the curve, while contraction of only the 
deeper connective tissue draws the side as well as the centre forward, 
and tends to place the ureters in or over the fold instead of at the pos- 
terior edge. Contraction of the anterior vaginal wall is also known 
by unusual difficulty in detecting the trigone and ureters through 
its hard, rough, thickened substance. Infiltration may cause the 
same difficulty, but will be known by the smooth, soft, and only 
slightly elastic, or doughy feel of the mucous membrane. Extreme or 
long-standing contraction of the vaginal wall is also accompanied by 
an extension of the rugae backward to the cervix and laterally into the 
anterior grooves and urethral fossae so as to narrow them, while a con- 
traction of only the connective tissue separates and elevates the grooves, 
and slightly increases their areas of smooth mucous membrane. 

The main signs of a relaxation of the anterior vaginal wall are 
smoothness and flabbiness of the mucous membrane without much 
change in the deeper tissues. When such relaxation occurs indepen- 
dent of the deeper tissues it is usually inferiorly about the urethra 



90 EXAMINATION OF THE FEMALE PELVIC OEG ANS. 

and is known by an increased area of smoothness or flabbiness about 
the urethral fossae and notches. An extensive loosening of the relaxed 
vagina from the pubic connective tissue attachments is recognized by 
a widening and depression, or obliteration, of the urethral fossa?, and 
a separation of the mucous membrane from its hard base at the notches, 
under the sub-pubic ligament, and a descent of the urethra under 
the pubic arch, with the apex of the trigone, the neck of the bladder. 
The inter-uretric ligaments are felt behind and near, but not below, 
the pubis. 

The posterior and lateral vaginal walls at the upper end of the va- 
gina feel soft and displaceable in the pelvic chamber about it, and 
only present firm resistance to deep pressure. Toward the introitus 
they become rugate and closely attached to the recto-vesical fascia, 
over the levator ani et vaginae muscles, on either side of the rectum. 
As upon the anterior wall, so here the rugae and closeness of attach- 
ment to the fascia at the introitus indicate the amount of contraction 
of the wall, and the condition of its underlying connective tissue. 
Deeper within the vagina the posterior wall may be held so high by 
the contractility of the structures that all characteristic resistance of 
underlying structures will be lost, as we frequently find in old nulli- 
para, and imperfectly developed young women. Or the tissues may 
be relaxed here as elsewhere and allow the finger to lie flat upon the 
pelvic floor. 

The rectal notches become deeper from relaxation of the vaginal 
entrance, for the mucous membrane is then no longer held up from the 
rectum. The posterior vaginal grooves, which are short in the virgin 
vagina and are soon lost to the touch in the elastic vaginal tube, become 
larger, deeper and more noticeable as the relaxed vagina allows the 
posterior wall to sink to the pelvic floor on either side of the rectum. 
Firm contraction, on the contrary, may render the posterior grooves 
so shallow as to be imperceptible to the finger. 

A softness, smoothness and puffiness of the posterior wall, forming a 
loose transverse fold at the introitus into which the examining finger is 
apt to catch, indicates a relaxation of the wall and a loosening from 
its connective tissue attachments to the rectum and pelvic floor. The 
posterior vaginal grooves and rectal notches then become either lost 
in the folds or displaced by being loosened from their base. In ex- 
treme cases the vaginal wall protrudes externally. The finger slipped 
into the rectum can easily ascertain if the whole recto-vaginal septum 
* is prolapsed, as in that case the anterior rectal wall is felt to pass into 
the mass. 

Rectal Examination of the Pelvic Roof. 

In cases of small, or contracted vaginae, imperforate hymen, displaced 
pelvic viscera, or diseases in the back part of the pelvis, it not unfre- 



METHOD OF RECTAL INDAGATION. 91 

quently becomes desirable or necessary to examine through the rectum. 
The advantage of such examination lies not only in the frequent un- 
fitness of the vagina, but in the shortness and directness of the route 
to the posterior superior parts of the pelvic cavity. 

Kectal indagation may be practised with one or two fingers or the 
half hand. The latter method usually requires either local or general 
anaesthesia. The introduction of the whole hand, as is often recom- 
mended, has been known to permanently impair the tonicity of the 
sphincters, and should not be resorted to unless the hand be small, 
the anus and rectum easily dilatable, and an accurate diagnosis be 
imperative and unattainable by milder measures. 

Method of Rectal Indagation. 
As the rectal mucous membrane is sensitive, comparatively dry, and 
collapsed into soft folds,, the examining finger should be abundantly 
lubricated with an absolutely unirritating ointment, and introduced 

Fig. 54. 



Method of Introducing the Finger into the Rectum Q). 
f l . Touching internal sphincter ani and lower edge of perineal septum ; f 2 , finger passed through 
the interior sphincter under the pelvic floor edge ; / 3 , finger turned back over pelvic floor edge 
for the examination of the pelvic interior. 

slowly with the palmar surface forward or to one side. The sphincter 
ani dilating toward the perineal body allows the finger to come in 
contact with the lower edge of the perineal septum where the rectal 
wall containing the second sphincter is attached (Fig., 31 is, also 34, s), 
and from w T hich it can be traced around the anus, a trifle farther from 
the external anal orifice behind than in front. Introduced straight 
upward in the axis of the body, the finger comes squarely against the 
posterior rectal Avail which here passes almost directly forward under 
the pelvic floor from the anus to the rectal promontory or pelvic floor 



92 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

edge. Ifcthe finger be directed slightly forward (Fig. 54, f and/ 2 ) the 
edge of the fibres of the levator ani at the promontory, which are 
normally relaxed and offer but little resistance, may be felt and pressed 
back out of the way (Fig. 54,/ s ). Should, however, much irritation 
exist, or be produced by rough fingering, the levator ani may con- 
tract and lift up the folded rectum against the posterior vaginal wall 
(Fi°;. 21) and effectually resist the unwarranted or awkward intrusion. 

The levator ani, holding the collapsed and closed rectum loosety 
forward, not only forms a boundary below which faeces never lodge, 
but has the power of firm voluntary contraction, and may, under 
pathological influences, contract so tightly and continuously as to 
interfere with the circulation and enervation of the parts passing 
through the pelvic floor outlet. Hence it would be in accordance 
with its function to call the anterior portion of the levator ani (the 
levator ani proper) the rectal sphincter or third sphincter of the bowel. 
(See Fig. 17). It is in reality the sphincter of the pelvic outlet, 

The finger as it enters the anus should therefore be gently directed 
forward along the perineal body (see Palpation of the Perineum) until 
the recto-vaginal septum is reached. Then by turning the finger end 
so as to make the perineal body recede upward and the pelvic floor 
edge backward the road becomes straight (Fig. 54, / 3 ). 

When the palmar surface is turned forward the finger, almost as 
soon as it has penetrated beyond the pelvic floor edge into the inner 
pelvic or subperitoneal connective-tissue chamber (see page 68), usually 
encounters the cervix which, being nearer the anus than the vulva, 
seems to the inexperienced touch too far forward, and, being covered 
by both a rectal and vaginal wall and a little intervening connective 
tissue, too large. 

If any doubt exists as to what is thus felt, a finger of the other hand, 
or a thumb of the same hand, may be slipped into the vagina to the 
cervix and serve as an indicator. When the cervix is far back and 
the fundus uteri turned down over the vesico-vaginal septum the 
corpus is felt as if it la} T upon the elevated anterior rectal wall. When 
the cervix is forward and the fundus turned back the finger end passes 
under and back of the cervix, instead of in front, and reaches under 
the corpus more readily than per vaginam. 

Although we may reach the smaller structures of the anterior half 
of the pelvic roof, such as the lower end of the ureters, round ligament, 
etc., in somewhat the same manner as through the vagina, the} 7 are 
obscured by more intervening connective tissue, and the resistance of 
the rectal walls. Hence, unless the vagina be closed or contracted, 
and the rectum quite lax we need not attempt such an exploration, 
but pass the finger on to the side of the cervix and hook it under the 
base of a broad ligament. This will be usually felt as a firm, well- 
defined band stretching to the side of the pelvis. In many cases the 
posterior peritoneal layer extending under and forming the sacral 



DIGITAL EXPLORATION THROUGH THE UPPER RECTUM. 93 

peritoneal pouch feels firm and is traceable back to where it is reflected 
up to form the sacro-uterine fold. The finger passed back under the 
pouch will, if the rectum be voluminous and lax, readily glide up into 
the Douglas pouch, and may be hooked over one of them. If the body 
of the uterus be turned back upon the recto-uterine peritoneal folds it 
may be pushed up from them. If the uterine appendices be in the 
pouch, they will be above and in front of the finger, instead of above and 
behind it, as in the vaginal examination, and can be palpated against 
the posterior wall of the cervix in front, instead of against the rectum 
behind ; or, if the fundus be turned back, they will be felt against the 
corpus uteri over and in front of the finger, instead of over and behind. 
Sometimes masses of faeces in the upper rectum may be felt pressing 
down behind and over the uterus, but separated from the finger by a 
rectal fold caused by the contracted fourth (called the third) sphincter, 
so as to feel something like the appendices, or some foreign substance, 
in the sacro-uterine pouch. Beside the possibility of mashing and 
working down such substance, there is always the possibility of getting 
beyond the rectal fold or constriction and in direct contact with it. 

In all these manipulations the rectal mucous membrane should feel 
soft and folded and freely movable upon the finger. Any alterations 
of its walls such as hardening, cicatrization, immobility, narrowing, 
inelasticity, unnatural heat, sensitiveness, and granular, hemorrhoidal 
or polypoid growths, etc., should be noticed, since they often have a 
material influence upon the condition of the sexual organs and upon 
the interpretation of the vaginal examination. 

If the connective tissue about the sacral peritoneal pouches be soft, 
ovaries or tubes lying low in them may be felt, and, if at the same 
time the abdominal walls be lax and depressible, almost the whole of 
the posterior half of the pelvis may be examined bimanually. In 
those who have borne many children this may frequently be accom- 
plished, in old nullipara very seldom. 

Digital Exploration through the Upper Rectum. 

As both the sacro-uterine ligaments and fourth sphincter, usually 
called the third (Figs. 34 and 35, D and D 1 ), are sometimes contracted 
and present openings of almost the same size, it is necessary, that the 
finger may not get lost in the rectal folds, to be able not only to find 
the rectal sphincter, but to know it from the ligament. It must, there- 
fore, be borne in mind that the contracted sacro-uterine ligaments 
have an oval or semicircular aperture against or inseparable from 
the cervix, and may be felt to pass upward toward the second sacral 
vertebra, while the contracted fourth sphincter is circular, separated 
or separable by a stretch of rectal wall from the cervix, and is against 
or near the lower end of the sacrum ; also that the ligaments are not, 
like the sphincter, completely enveloped in puckered mucous mem- 



94 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



brane, inseparable from it, and dilatable by traction upon it. Hence, 
instead of pushing the rectal wall up behind the cervix, we must 
direct the finger back toward the sacrum until it enters the sphincter. 
If the latter be closed, forward traction upon the rectal wall will 
usually dilate it sufficiently for the finger to enter it and pull it open 
in the direction of the cervix, and thus open up a direct route between 
the sacro-uterine folds to the sacral promontory out upon the pelvic 
roof. Two fingers of the right hand are best for such an examination. 

Fig. 55. 




Bimanual Examination of the Posterior Surface of the Uterus and the Posterior Pelvic 
Spaces from the Rectum. (After a case of Hematoma.) 

If, while we press well up behind the uterus with the rectal fingers, 
we bring the fingers of the other hand down behind the fundus from 
the surface of the abdomen, we may approximate them behind the 
uterus. When the parts are relaxed and not irritable, this can occa- 
sionally be done with one finger in the vagina, and without an an- 
aesthetic. Fig. 55 represents such an examination made with one 
finger in the rectum without an anaesthetic, in a case of hematoma 
extending from one broad ligament across the posterior wall of the 



CIRCUMDIGITATIOX OF THE UTERUS, ETC 



95 



uterus into the other. The broad ligaments can be examined at the 
same time in the same way, and the changes which occur be quite 
accurately estimated. With two fingers higher in the rectum, and the 
patient anaesthetized, the uterus is not pulled so far forward as repre- 
sented in Fig. oo. 

In all central and posterior positions of the ovaries they are found 
within easy reach of the fingers passed into the upper rectum. The 
fingers seem right among and against the ovaries, tubes, ligaments, 
arteries, small intestines, etc., and can, with a little experience, map 
them upon the mind. Indeed, when thus carefully and intelligently 
examined, the pelvis has no secret places, except those of a micro- 
scopic kind. 

The Recto- Vaginal Grip. 

AY hen the fundus is turned into the hollow of the sacrum the 
uterus may usually be firmly grasped between the forefinger in the 



Fig. 56. 




Recto-Vaginal Grip of the Retroverted Uterus (}/Q. 

rectum behind the fundus and the thumb in the vagina in front of 
the cervix, and its flexibility, mobility, and sensitiveness accurately 
and satisfactorily determined (Fig. 56). 



Circumdigitation of the Uterus from the Abdomen, Vagina, and Rectum. 

A combination of these different methods of examination is useful 
in some cases. By introducing one or two fingers into the rectum 
and behind the cervix, the thumb of the same hand into the vagina 
in front of the cervix, the thumb of the other hand against the de- 
pressed abdominal wall below the fundus, and the fingers similarly 



96 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



over the fundus, the uterus can be grasped simultaneously by the 
fundus and cervix in a firm double grip, as represented in Fig. 57. 



Fig. 57. 




Bimanual Circurndigitation from the Rectum and Vagina, by means of the Abdominal 
and Recto-Vaginal, or double, Grip. 

Thus not only the size and shape of the organ can be estimated, but 
also its hardness, flexibility, and mobility. The ovaries may, during 
anaesthesia, be similarly grasped. 

Palpation of the Interior of the Bladder. 

When abnormal or pathological conditions interfere with ordinary 
methods, it may become necessary to introduce the ringer into the 
bladder to ascertain the condition of its mucous membrane, or to reach 
the anterior part of the pelvic cavity. The urethra should be dilated 
first with sounds or dilators (see " Use of the Urethral Speculum," 
chap. IV.) and the little finger. After the little finger, the index may 
be gradually forced into the bladder. About an inch back of the 
vesical sphincter and about an inch apart will be felt the slightly 
elevated mouths of the ureters (see Fig. 58). The thumb of the same 
hand, or a finger of the other, introduced in the vagina can, by locat- 



PALPATION OF THE INTERIOR OF THE BLADDER. 



97 



ing the ureters in the vagina and passing up the vesicovaginal septum, 
sometimes aid the index in the bladder. The bladder being high up 
in the pelvis gives access to the vesico-uterine tissue and pelvic brim 
better than does the vagina. But the skill required to palpate through 



Fig. 58. 




TrL 



Palpation of Uretral Orifices (after Winckel). 



the constricting urethra, the violence necessarily done to the parts, 
and the rarity of the occasions demanding such an examination must 
make it possible for but few to derive much benefit from it. 



For the palpation of the vessels and nerves of the pelvic roof see " Palpation of the 
Arteries of the Pelvis," Chapter III. p. 104, and the following paragraphs. 



CHAPTEE III 

EXAMINATION OF THE FEMALE PELVIC OEGANS {Continued). 

The Pelvic Floor and Perineum. 

As a rule the pelvic floor of the child bearing woman may be suffi- 
ciently examined from the vagina. When, however, the vagina does 
not permit of as satisfactory an exploration as is desirable, rectal 
indagation may become necessary. Hence, we will take up each in 
turn, first the vaginal, then the rectal. 

Vaginal Palpation of the Pelvic Floor. 
The Coccyx. — One or two fingers, introduced to the cervix uteri as a 
starting-point, may commence the palpation of the pelvic floor by 
pressing downward and backward in the median line until the knotty 



Fig. 59. 




5] :ng the Coccyx between the thumb externally and the index in the vagina. The 
rectum is pushed to one side. 

ridge of bone corresponding to the anterior surface of the coccyx is 
reached. The rectum, if in the way. should be pushed to one side, 
usually to the left. By bringing the finger forward along the ridge to 
the point where it glides over upon softer tissue the end of the bone 
will be distinctly recognized. In a young or poorly developed nulli- 



THE PYRIFORMIS. 99 

par, and in one who has recently borne children, the tip of the coccyx 
is depressible and elastic. In the fully developed nullipar and in the 
aged this mobility diminishes year by year and is sometimes imper- 
ceptible. A rigidity or temporary contraction of the levator ani, by 
raising and hardening the pelvic floor, makes the recognition of the 
tip of the bone quite difficult unless firm pressure be used. 

When a more definite knowledge of the size, mobility and position 
of the coccyx is desired, the thumb should be brought externally 
against the coccyx, an inch or a little further back of the anus, so that 
the bone comes between the index finger in the vagina, and the thumb 
on the integument externally, as represented in Fig. 59. Unless the 
patient be very fleshy and the perineum very rigid the bone will be 
grasped without difficulty. 

The presence of rigidity, ankylosis, displacement, tenderness, hyper- 
esthesia, etc., of the coccyx can thus be definitely ascertained. In 
the young and the parous woman the tip of the bone may be moved 
forward and backward like a piece of soft whalebone ; in nulliparous 
middle age, and in old age in general, it may be moved but little and 
only by considerable pressure. If there be immobility due to contrac- 
tion of the muscles of the pelvic floor, their resistance may be overcome 
by firm pressure, or relaxation may be brought about by changing the 
position of the patient. 

The Small Sacro- Sciatic Ligament, and Ischial Spine, 

By passing the finger back on either side of the rectum the small 
sacro- sciatic ligament is felt running from the lower end of the sacrum 
and upper end of the coccyx to the ischial spine. When the pelvic 
floor is relaxed the finger immediately recognizes it, for its anterior 
edge is raised and hard as compared with the softer muscles in front. 
W T hen the pelvic floor is contracted the posterior edge of the ligament 
is the only part of it to attract attention as the finger passes over it into 
the great sciatic foramen. The ischial spine is felt, at the converging 
outer ends of its hard edges, as a small bony projection in front of the 
foramen, with a slight linear depression (the white line or arcus ten- 
dineus) leading forward, and marking the junction of the pelvic wall 
and pelvic floor. (Figs. 18 and 19.) 

The Pyriformis. 

Behind the small sacro-sciatic ligament may be felt the pyriformis 
muscle which, in a state of rest, is flat, and considerably softer than 
the ligament; but which, during contraction, feels like a small pear- 
shaped tumor lying upon the sacrum, filling the upper part of the 
sacro-sciatic foramen and reaching with its smaller tapering end 
diagonally downward and outward behind the ischial spine. By 



100 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



directing the patient to rotate the thigh inward and outward or raise 
her hips a little, or by slightly changing her position, or that of her 
feet, or approximating her knees, contraction and relaxation of the 
muscle may be successively evoked. 



The Great Sacro-Sciatic Foramen and Sacral Promontory. 

Pushing the finger from the ischial spine across the smaller end of 
the muscle, upward and backward, the bony upper border of the great 
sciatic foramen at the sacro-iliac synchondroses is felt, and may be 

Fig. 60. 
Trorn ontv-rif 




Anterior Surface of the Sacrum, showing the Attachment of the Pyriformis. (After Gray.) 

traced toward the median line. Farther up the promontory may be felt. 
The upper border of the great sacro-sciatic foramen may often be 
reached with two ringers in ordinary office examinations, whereas the 
promontory can be thus touched only when the vagina and perineum 
are relaxed and the parts behind the uterus are devoid of any unusual 
sensitiveness. The projecting edges of the sacral foramina can also be 
easily felt, the first one just above the internal and upper angle of the 



THE LEVATOR ANI. 101 

raised belly of the contracted pyriformis muscle, the second and third 
at the depressions or scallops of its internal border, and the fourth just 
internal to its lower angle or edge. (See Fig. 60.) 

The Coccygeus. 

Coming forward over the small sacro-sciatic ligament the finger 
barely detects the fibrous structure of the flattened coccygeus lying 
upon it, until it has passed the ligament, when it immediately recog- 
nizes the depressible semi-elastic character of the relaxed anterior por- 
tion of the muscle. Its anterior edge or border is often prominent as 
compared with the levator ani in front of it, and may be known by 
locating the ischial spine and last coccygeal articulation, between 
which it runs in a straight line. The anterior border of the ligament 
may be known from that of the muscle not only by its rigidity, but 
also by its direction, which is more backward from the ischial spine 
toward the middle or upper part of the coccyx than the muscle. In 
the ordinary dorsal position the border of the ligament seems to run 
from the ischial spine inward and slightly backward, that of the muscle 
inward and slightly forward. When the coccygeus is contracted, firm 
pressure will be required to reach and recognize the anterior edge of 
the ligament through the substance of the overlapping muscle. 

The Levator Ani. 

The levator ani, occupying almost the entire pelvic floor in front of 
the coccygeus, lies directly under the finger pressed flat upon the 
pelvic floor beside the rectum. When relaxed it is soft, concave and 
depressible, and can be excited to partial or irregular contractions by 
hooking the finger tip into it at various points. When contracted 
in all its parts it renders the pelvic floor hard, less concave and holds 
it up firmly against the anterior vaginal wall. Simultaneous contrac- 
tion of the coccygeus produces a smooth, hard floor as far back as 
the great sciatic foramen. If, as often happens in ordinary exami- 
nations, the central portion alone is contracted, the finger after en- 
tering the vagina comes upon a large ridge of muscular fibres, ex- 
tending from the posterior surface of the pubic bone, at the anterior 
end of the white line backwards and inwards straight to the end of the 
coccyx forming a levator coccygei rather than a levator ani. This is 
the posterior half of the pubo-coccygeus of Savage. (Fig. 18, 1 .) Behind 
it is felt the relaxed posterior portion as a triangular depression whose 
base is the white line (arcus tenclineus), whose apex is at the lower 
coccygeal bone and whose sides are the anterior edge of the coccygeus 
behind and the contracted portion in front. This is the obturato- 
coccygeus of Savage. (Fig. 18, 2 .) If the coccygeus be also soft and 
relaxed, the depression including it will be quadrilateral.. If the 



102 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

middle section of the levator ani be very strongly contracted, the tri- 
angular space often becomes narrower by a participation of some of 
its anterior fibres in the contraction. If the fibres in front of this con- 
tracted band or central portion of the muscle be relaxed, the finger 
presses down with the rectum against the coccygeo-anal ligament ; if 
they be greatly relaxed this central band becomes more prominent, 
and the finger lies upon an almost flat surface having an entirely dif- 
ferent plane from the deeper pelvic floor, and turning abruptly from 
it, instead of continuing forward. As thus felt the anterior portions of 
the levatores ani. of both sides taken together form a large triangle 
whose apex is at the tip of the coccyx, and whose basal angles are at 
the pubic attachments of the contracted central portion or levatores 
coccygei. 

When the posterior section alone is contracted it seems to form a 
continuation forward of the contracted coccygeus, and sometimes 
whether contracted alone or with the whole floor draws the white line 
into a slight curve whose concavity is outwards. A contraction of only 
the anterior portion, which has no central bony attachment, raises the 
pelvic floor edge and recto-vaginal promontory over it so as to place a 
distinct fleshy ridge across the vaginal inlet behind which the finger 
end passes abruptly back to the deeper and softer parts. Contraction 
of the central with the anterior portion makes this ridge much wider. 
[See Fig. 21.) 

Figs. 18 and 19, from Savage, show quite truthfully the origin and 
insertion of the different sets of fibres of these muscles and are worthy 
of a close study. The finger-end by pressing into the muscles at vari- 
ous points as already directed can easily determine the direction and 
action of the fibres during the irregular contractions thus induced. 

Control of the Pelvic Floor Muscles by Will. 

As the levator ani and, to a certain extent, the coccygeus are volun- 
tary muscles, the patient can be made to elevate this part of the pelvic 
floor as the finger lies upon it, My attention was called to the con- 
trol of the will over the levator ani by an interesting article by Budin* 
in which he asserts that some women can voluntarily contract the 
levator ani. For the purpose of getting at the facts I tested the mat- 
ter in seventy-five consecutive gynecological patients in office practice. 
I asked them, while holding my finger in the vagina, to contract the 
anus as after a stool, or as to prevent a passage from the bowels. By 
telling them that I was trying the strength of the uterine supports I 
succeeded in getting all but one to make the effort. All but this one 
succeeded in raising the anterior or middle portions ; nearly all raised 
also the coccygeus ; and about ten per cent, raised the whole plane of 



Obstetrique et Gynecologie, 1886. Le Progres Medical, August, 1881. 



THE OBTURATOR INTERNUS. 103 

the pelvic floor from the coccygeus forward. In a few cases the ante- 
rior and middle portions were raised along with the levator vaginae so 
high that the finger had to pass up behind the pubes to get over them, 
i.e., the pelvic outlet was voluntarily closed up. Fig. 21 represents in 
section a contracted pelvic floor through the median line or lowest 
part. Virgins seemed to have as good control over the pelvic floor as 
multipara and married nullipara. Injuries during labor impair the 
contractile power of the pelvic floor and perineum in many, as will be 
explained in describing the injuries of these parts. 

The Obturator Internus. 

The relaxed internal obturator muscle is seldom felt in an ordinary 
examination unless especially sought for. It lies flat over the obtu- 
rator foramen, partly under the levator ani and white line of division 
of the obturator fascia, and partly above them on the lateral pelvic 
wall. (See Fig. 15.) Its higher portion is easily detected above the 
white line cushioning the pelvic wall, while the remainder may be 
reached by depressing the relaxed middle and posterior portions of 
the levator ani downward and outward through the ischio-rectal fossa 
until firm resistance is encountered. When contracted, however, the 
obturator internus feels like a hard hemispherical tumor on either side 
of the median line, over the obturator foramen, filling the ischio-rectal 
fossa, and elevating the pelvic floor. Between the two bellies there 
extends a narrow, deep characteristic groove along the median line 
whose bottom is the coccyx and ano-coccygeal ligament. By pushing- 
aside the rectum which loosely fills the groove, the borders of the hard 
belly of the contracted muscle may be easily traced. 

We may distinguish these muscles from adventitious growths by the 
fact that they are bilateral, or may be made so by causing the patient 
to rotate the trochanters outward against counter-pressure ; and that 
at the same time the pyriform muscles are generally found contracted, 
tumor like; while the depressed flat surface of the small sacro-sciatic 
ligament lies normally between the two rounded tumors. When in 
addition to contraction of the obturator internus and pyriformis, the 
levator ani and coccygeus are also contracted, the finger finds the pos- 
terior vaginal wall and whole pelvic floor elevated and extending as a 
hard mass almost straight back from the recto-vaginal promontory to 
the small sacro-sciatic ligament. This ligament, instead of a raised, 
flat, hard surface in front of a soft and yielding, somewhat concave 
pelvic floor, is now a narrow, depressed surface behind a firm flat or 
convex surface, and in front of the raised, tapering belly of the pyri- 
formis. When the levator ani, the coccygeus and the pyriformis are 
contracted but the obturator internus relaxed, the ligament is depressed 
compared with the pyriformis behind, but is about on a level plane 
with the muscles in front. 



104 EXAMINATION OF THE FEMALE PELVIC OEOANS. 

Rectal Examination of the Pelvic Floor. 

As already indicated in speaking of the rectal examination of the 
pelvic roof, p. 90, the finger, as soon as it has passed the anal sphinc- 
ters comes in contact with the posterior wall of the rectum as loosely 
held forward by the anterior portion of the levator ani. This is the 
part that is often felt per vaginam to be soft and depressible in front 
of the contracted middle portion, or levator coccygei. When it is re- 
laxed its resistance is scarcely felt by the well oiled and properly 
directed finger; but when contracted it forms a firm edge or projection 
almost closing the passage (Fig. 54). In order to get over it upon the pel- 
vic floor without exciting it to rigid contraction, the finger, after being 
introduced forward to the anterior rectal wall, or near it (Fig. 54, /*), 
should be turned palmar surface backward (unless it has been so in- 
troduced), and bent as it passes further in, so as to hook around and 
depress the pelvic floor edge or rectal promontory. The rectum will 
be felt to lie immediately upon the pelvic floor so as to afford, practi- 
cally speaking, a direct palpation of its centre and often of its left side, 
and if it be voluminous or relaxed, of the whole pelvic floor. The 
ischio-rectal fossa on either side is separated from the finger by less 
tissue than in the vaginal examination. On the contrary, the junction 
of the pelvic floor with the lateral pelvic walls anteriorly cannot be 
reached as easily through the vagina which lies higher in the pelvic 
connective tissue chamber. 

The nearness of all parts of the pelvic floor, the apparent narrow- 
ness of the levator ani et vaginae which is partly in front of the finger, 
the distinctness of the sensations of touch, and the absence of certain 
parts that are felt in the vaginal examination, may be somewhat con- 
fusing to the beginner, but constitute in reality the reason for such an 
examination. Having located the coccyx, ischial spine and smaller 
sciatic ligament as per vaginam, the location of the other parts becomes 
easy. With one finger the sacrum can be explored as high up as the 
pelvic roof, its curve and that of the coccyx be estimated, and the 
lower contents of its hollow be examined with the gentlest and most 
discriminating touch. 

Contraction, relaxation, irritability, inefficiency, etc., of the muscles 
of the pelvic floor are more easily appreciated and studied than when 
felt through the vagina, where the levator vaginas, vaginal wall, rectum, 
and connective tissue, as well as the greater distance of the parts, 
render the sensations less distinct. 

Palpation of the Arteries of the Pelvis. 

In palpating an artery in the pelvis, we hold the finger perfectly 
still, after finding the tissues through which the vessel runs, until we 
detect its pulsations, and then trace it by them in both directions. 



VAGINAL PALPATION OF ARTERIES 105 

When pressed against a hard or resistant surface it feels like a cord, 
and may, if passed by in haste, be mistaken for other structures, such 
as the ureters, a deep cicatrix, a nerve, a tendon, ligament, etc. 

Vaginal Palpation of Arteries. 

The pulsating uterine artery is found on either side of the cervix by 
pressing high up in the anterior or posterior fornix and then around 
to the side of the uterus, or by pressing straight out from the lateral 
fornix and up under the base of the broad ligament. The firmness 
of the connective tissue about the artery, or the resistance of the vagi- 
nal walls, may, however, frustrate such attempts. When the cervix is 
situated well back the artery is often found farther back than would 
be supposed. By hooking the finger up behind the outer attachment 
of the base of the broad ligament the uterine artery may occasionally 
be felt entering the broad ligament. When found beside the cervix it 
may sometimes be traced to its origin above and behind the ischial 
spine. 

A vaginal branch may nearly always be felt pulsating near or against 
the cervix, in front and to the side of it, and can be traced laterally 
almost to the main vessel and forward down the anterior vaginal wall. 
Sometimes it dips into the connective tissue, or divides irregularly and 
is lost to the touch near the cervix. 

The middle vesical artery is often felt traversing the pelvic roof near 
the ureter, and may be known from it by its pulsations. 

The internal epigastric artery can also be reached and recognized by 
depressing the abdominal wall with the hand externally over the mid- 
dle of Poupart's ligament, and pressing up the vaginal finger about the 
internal abdominal ring. (See Palpation of the Round Ligament, p. 
74.) The pulsations may be traced from the ring a short distance up 
the abdominal walls. Numerous small tendons on the under surface 
of the transversalis, passing in various directions, tend to confuse the 
touch, but may be known by the absence of pulsations in them. 

The internal pudic, escaping at a point above and behind the ischial 
spine, may be felt by passing the finger tip over and behind the ischial 
spine along the pelvic wall below the uterine artery, or by placing the 
finger end upon the pyriformis muscle and carrying it forward to the 
spine. It is felt to pass into (really out through) the great sacro- 
sciatic foramen in front of the muscle. Just internal and back of the 
pudic, usually separated by a sacral nerve running between them, is 
felt the sciatic also passing out. Being large arteries and so near 
together they may be both felt at the same time and recognized by being 
together and disappearing so near together. When they are given off 
very low, only one artery, the anterior trunk of the internal iliac, may 
be felt in their place pulsating strongly as far down as the sacral 
plexus. 



106 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

By pushing backwards across the pyriformis the gluteal artery is felt 
to pass down and disappear behind and external to it. When the upper 
border of the greater sciatic foramen can be reached, the gluteal will be 
found pulsating strongly as it comes between the finger and the bony 
edge. It may be traced downward to the edge of the muscle and- 
upward to the internal iliac. 

The middle hemorrhoidal is easily traced downward and inward 
from behind the ischial spine toward the rectum, to disappear at the 
recto-vaginal septum near where the os uteri impinges against the 
posterior vaginal wall. 

The inferior vesical, given off from the middle hemorrhoidal, or near 
it, is felt internal to and below the ischial spine and can be palpated 
upon the levator ani laterally a short distance below r the obturator to 
the sides of the pelvic floor outlet. The finger introduced into the 
vaginal entrance and laid flat upon the belly of the levator ani on 
either side will almost immediately feel the artery pulsating and can 
trace it backward. 

The obturator artery is easily felt running forward along the lateral 
pelvic wall, over the spine of the ischium near the upper edge of the 
obturator interims toward the opening through which it leaves the 
pelvis. Its course lies a little above and almost parallel with the white 
line. From here a branch can usually be traced along the posterior 
surface of the pubic bone to join its fellow from the opposite side. 
An obturator branch of the epigastric can generally be traced from the 
foramen upward and forward toward the internal abdominal ring, to 
which it may sometimes serve as a guide. 

The sacra-media may often be recognized per vaginam by pressing 
firmly against the sacrum in the median line high up behind the 
cervix. On account of its bony bed the pulsations seem quite strong. 
Satisfactory palpation of the smaller arteries situated at a distance 
from hard or bony surfaces is only possible w r hen the connective tissue 
is not too firm, or when their course is near the mucous membrane of 
the vagina, or when the abdominal wall can be pressed down so as to 
form a resistant surface over them. The main trunks of the internal 
iliacs can, under favorable circumstances and under ether, be found by 
tracing the anterior and posterior branches upward. 

The irregularities in size and origin of the vesical, uterine obturator, 
and pudic arteries in different subjects, and in the two sides of the 
same subject, and the occasional crowding together or union of the 
points of origin of two or more, or of all, of the branches of the internal 
iliacs, make it often impossible to trace them all to and from their 
sources. 

In a dissection made for the purpose of a description I found both sides unusual and 
at the same time as different from each other as possible. The places of division of 
both internal iliacs were high ap, and both obturator arteries were given off from the 



PALPATION OF PELVIC NERVES. 107 

posterior trunks. On the left side the anterior trunk was less than an inch long to 
where it bifurcated into the sciatic and pndic. The uterine and superior vesical arose 
by a common track, the first giving off the vaginal, the second the middle vesical. The 
middle hemorrhoidal gave off the inferior vesical. On the right side the anterior 
trunk extended as an almost straight tube for more than two inches and divided into 
the internal pudic and sciatic just over the sacral plexus. The only other branches 
given off were the superior vesical, with its middle vesical branch, and the uterine 
artery. This last was given off high up, and descended beside the long anterior trunk 
of the internal iliac for about an inch before turning into the broad ligament. All of 
the other arteries arose from the posterior trunk. This variability in the different 
subjects, and in the sides of the same subject is a strong reason for the practice of 
digital palpation of the arteries, so that the operator need not depend upon his knowl- 
edge of where they ought to be, but may map them out with the finger as they happen 
to be before cutting in among them. 

Rectal Palpation of the Pelvic Arteries. 

When the rectum is of moderate size, and normally located a trifle 
to the left, the index finger of the right hand introduced into it 
scarcely notices any arteries except the sacra-media, unless it presses 
far toward the right side of the pelvis ; but the left index, if introduced 
and allowed to lie still a moment, is apt to feel as if in a nest of pulsat- 
ing arteries, and to get confused at the number of vessels about it — 
more particularly so as smaller branches are here palpable. The small 
sciatic ligament and pubic spine should in such a case be located, or, 
if the pelvic floor be raised so as to hide them, the contracted pyri- 
formis and great sacro-sciatic notch. The vessels before and behind 
the pyriformis may then be sought the same as directed above in the 
vaginal examination, and will be reached with greater ease. Those 
passing across the pelvic roof are, however, not so easily recognized. 
The middle hemorrhoidal will be above instead of below the finger, 
and may often be pressed against the cervix. 

Palpation of Pelvic Nerves. 

Nerves to be felt in the pelvis must usually be pressed against a hard 
surface. As a rule they are to be sought near the arteries of the same 
name. Thus the obturator nerve may be reached from the vagina 
lying against the hard pelvic wall, a little above and parallel to the 
obturator artery, and the superior gluteal and pudic nerves beside the 
arteries of the same name. The sacral plexus lying upon the pyri- 
formis feels like flat, slightly movable bands connected together, coming 
from the sacral foramina and disappearing with the tendon of the 
muscle behind the ischial spine. The mobility of this plexus and the 
ease of its detection also affords a sort of index to the firmness of the 
connective tissue about them. Although thus exposed to easy pressure 
by the finger in the vagina, they are in reality well protected by lying 
in the sacral concavity, with large arteries about them, and the sacro- 



108 EXAMINATION" OF THE FEMALE PELVIC OEGANS. 

uterine and broad ligaments and sacral pouches extending above and 
over them. Inflammatory exudations cause pressure upon them more 
often than anything else, although I have seen one case of pressure 
from a suddenly dislocated fundus uteri upon the superior gluteal, caus- 
ing intense suffering throughout the extent of the nerve, until as sud- 
den and permanent relief was afforded by a replacement of the organ. 
Pain upon pressure running along the course of the nerves is often 
a great help in hunting for them. Thus in palpating the superior edge 
of the greater sciatic foramen (p. 100), when we pass over the pulsating 
gluteal artery we can feel the nerve as a smaller cord running alongside 
it, and will know it by the sudden sharp pain felt by the patient as 
the nerve slips under the finger. The pain is referred to the hip and 
gluteal muscles. Similarly in front of the pyriformis, and near the 
respective arteries firm pressure upon the small sciatic or pudic nerves 
will sometimes be referred to the jjosterior and inner side of the upper 
thigh or about the external genitals. Pressure upon or above the 
coccygeus near the median line frequently causes acute pain in the 
pelvic floor along the course of branches of the 4th and 5th sacral 

nerves. 

Examination of the Perineum. 

In considering the perineum as separated from the pelvic floor 
(see Chapter I.) the levator vaginae portion of the levator ani was 
described as a separate muscle attached anteriorly to the posterior 
surface of the pubes, just external to the urethral notch, and poste- 
riorly to the recto-vaginal septum just behind the hymen. (Figs. 16, 
17, 22 and 31.) 

Examination of the Vaginal Orifice. 

The Hymen. — The hymen extends from the urethra just behind the 
meatus urinarius down, on either side, along the perineal septum to the 
perineal body, forming a curtain or screen at the vaginal orifice across 
the lower ends of the urethral and rectal notches. (See Fig. 16 for 
these notches.) According as its aperture is central or peripheral, 
high or low, single or double, etc., the shape of the ridge of membrane 
around the vaginal orifice varies, but to the finger passed into the 
vagina it usually feels like a firm, narrow ridge or elastic ring. When 
dilated or partially ruptured from coitus it is felt as one or more loose 
ribbon-like folds of membrane extending partly or quite around the 
vaginal orifice ; when destroyed by parturition its remains are felt as 
a series of soft projections (the caruncles) in the same place, or a trifle 
external to it; when absorbed or atrophied from injury or age it may 
leave no trace of itself to the touch, and but little to the sight. 

The Levator Vaginae and Levator Ani. 

In the virgin the posterior and lateral vaginal walls should, by the 
action of the levator vaginae or vaginal sphincter, be firmly approxi- 



THE LEVATOR VAGINA AND LEVATOR ANI. 109 

mated to the finger introduced through the hymen. The muscle ex- 
tends around the vagina and feels like a broad band or sling instead 
of a narrow rigid edge like the uninjured hymen (Figs. 17 and 22). 
Above on either side of the urethra are felt, upon upward pressure, the 
urethral notches giving the orifice a crescent shape (Fig. 61). In the 
married woman the levator vaginas is ordinarily somewhat relaxed, 
and sinks slightly into the rectal grooves on either side of the rectum, 
causing the latter to present a broad elevation, the recto-vaginal pro- 
montory just behind the hymen in the median line (Fig. 16) where it 
passes over the pelvic floor edge into (or out of) the pelvis. The orifice 
then is felt to be transversely oblong with the upper and lower sides 
depressed by the urethra and rectum (Fig. 62). To the touch the 
vaginal entrance feels a little wider over the rectum than in Fig. 16 
(which represents the parts collapsed), because when the parts are 
examined by the finger they reveal the shape and capacity only when 
dilated to the extent of affording a characteristic resistance. When 

Fig. 61. Fig. 62 Fig. 63. 

Jt . UrithxdZJToteJv -J>u% ie Arch 

\ . A , Urethra. .., ~ 

■ -pubcc Arch y ,.-— --. 

\"'" V'"' "—--.. y'''/y^ s \. A^fesl^ ?v$te Arth, 




ZtereafrAJ < Recto-vernal FroTnontcry tUu - tca ro ™ oni V 

Fig. 61.— Vaginal Entrance of the Virgin. 
Fig. 62.— Vaginal Entrance of the Married Nullipar. 

Fig. 63.— Vaginal Entrance of the Married Nullipar with contracted or short Levator Ani, draw- 
ing forward the rectal and recto-vaginal promontories. 

the anterior portion of the levator ani, that portion which passes to 
and under the rectum, is contracted or normally short, the rectum is 
pressed firmly up against the urethra, leaving a little space on either 
side between the rectal and urethral notches (Fig. 63). 

When the levator vaginas and its surrounding fasciae are relaxed to 
an extreme degree, so as to give no resistance whatever, the urethral 
notches are considerably widened to the touch, for the finger before 
encountering resistance comes against the fibres of the levator ani 
proper, whose pubic attachments are farther away from the urethra. 
These fibres, instead of passing almost straight back at their commence- 
ment, like the levator vaginas, assume from their origin a diagonal 
direction and converge quite rapidly inward towards the sides of the 
rectum. The finger finds itself in a V-shaped orifice with the rectum 
filling the angle and the urethra projecting into its open end. Fig. 64 
shows approximately the shape as ascertained by the touch. When 



110 



EXAMINATION OF THE FEMALE PELVIC ORGAKS. 



the levator vaginae is greatly relaxed, and the levator ani short or con- 
tracted, the rectum is brought up against the urethra and the borders 
of the levator ani or arms of the V are more transverse and form a 
larger angle, as in Fig. 65. The rectal notches are well marked, and 
broad but shallow. When the levator vaginae is extremely relaxed 
the finger entering the vagina along its posterior wall on either side 
of the recto-vaginal promontory comes against the under surface of 
the pelvic floor edge or levator ani instead of being directed imme- 
diately over it, as is the case when the vaginal entrance is drawn to- 
gether at the pelvic floor edge by the levator vaginae. 

Each of these forms denotes a particular condition: the first (Fig. 
61), a contracted or tonic condition of the vaginal coats, in the levator 
vaginae, the fascia and the surrounding connective tissue, and is found 



Fig. 64. 
ITrefkral TtoUhe^ 




Fig. 65. 



TJr&ilvrcL 




/ 






Telvlc floox. Sd^e> 



Fig. 64.— Vaginal Entrance, with great] y relaxed or destroyed Levator Vaginas. 
Fig. 65.— Same as Fig. 64, except that the Levator Ani is short and practically closes the Vagina 
(just behind its entrance). 



in virgins and some married nullipara; the second (Fig. 62), a normal 
relaxation of these tissues, and is found in some virgins and most 
married women; the third, contraction of the anterior edge of the 
levator ani so as to raise the pelvic floor edge (Fig. 63); the fourth, 
complete relaxation of the levator vaginae with a normal levator ani, 
as is found after over-distension or injury at childbirth (Fig. 64) ; the 
fifth, complete relaxation of the levator vaginae with shortness or con- 
traction of the levator ani anteriorly (Fig. 65). With the last condi- 
tion we may have a firm closure of the vagina just behind the hymen 
coexistent with relaxed or patent vaginal or vulval orifices. 



Examination of the Vulval Orifice. 

The vulval orifice usually feels larger than the vaginal. Anteriorly 
it is slightly indented by the urethra but extends posteriorly beyond 
the rectal promontory to the fourchette. 



THE PUBIC FOSSA. 



Ill 



The Constrictor Cunni or Vulval Sphincter. 

The principal variations in the shape of the vulval orifice are occa- 
sioned by the condition of the constrictor cunni. When this muscle 
and the surrounding fasciae are firm, as in some virgins, the opening 
feels almost circular to the finger sweeping around it, except at the 
anterior portion or lower end of the urethra (Fig. 66); when normally 
relaxed, as in married nullipara, it is about the same shape but large 
and flabby, and slightly indented below by the median line raphe 
(Fig. 67) ; when unusually relaxed from overdistension in labor, mus- 
cular debility, frequent coitus, etc., it allows the finger to pass from 
the inferior pubic ligament down along the inner surface of the pubic 
ramus for a considerable distance, and then against the perineal body 



Fig. 



Fig. 67. 



Fig. 68. 



v v 



IfrfChcvZ noddies 

\ ^x urethra, 
\ — -*-A. .^ 




le^e of con-iorcct^r came ^owrchettt Jte lo xtd Constrictor Ciotn v 

Fig. 66.— Shape of Vulval Orifice of Virgin as expanded by the Examining Finger. 
Fig. 67. — Same, of Married Nullipar. 
Fig. 6S— Same, of Childbearing Woman. 



in a slight depression between the median line raphe of the perineal 
body and the bone (Fig. 68). The sagging of the muscle on either side 
makes the fourchette and raphe between them feel like a raised ridge. 
The figure then traced becomes wider below than normal and has a 
distinct indenture both anteriorly and posteriorly, viz., the urethra 
and median line raphe. 

The Pubic Fossa. 

Extreme relaxation or a loss of integrity of both the levator vaginae 
and the constrictor cunni with their fasciae not only enlarges the vulvo- 
vaginal outlet so as to allow the pubic rami to be palpated down some 
distance below the superior pubic ligament, but gives rise on either 
side to a distinct well-defined fossa between the muscles. The base 
or bottom of this pubic fossa is the inner surface of the pubic ramus ; 
its external border is the relaxed constrictor cunni and the labium 



112 EXAMINATION OF THE FEMALE PELVIC ORGANS. 

majus ; its internal border is the levator vaginae and underlying 
anterior edge of the levator ani ; its anterior end is the inferior pubic 
ligament, and its posterior end the raised or projecting perineal raphe 
at and behind the fourchette * 

The distance below the inferior pubic ligament to which the pubic 
ramus can be traced is in proportion to the relaxation or destruction 
of these tissues. In the virgin the bone cannot be felt because the 
hymen and perineal septum keep the tissues between the levator 
vaginas and constrictor cunni raised from their level instead of 
depressed between them. When the hymen and perineal septum are 
stretched, the mucous membrane sinks slightly into this fossa and 
divides it into two narrow grooves, continuous in front with the fossa 
navicularis, and behind with a corresponding fossa behind the hymen. 
A rupture of the hymen involving a little of the perineal septum 
about it, allows the tissues to sink laterally against the pubic rami so 
as to form the fossa without any relaxation of the muscles, except 
such as must result from the rupture and the consequent fascial 
deficiency. 

Transversus Perinsei. 

When the pubic fossa is well marked the transversus perinsei can 
be palpated. A prolongation of the pubic fossa backward, allowing 
the finger to pass back along the pubic and ischial rami beyond the 
median line raphe and beside the anal sphincter, is presumptive evi- 
dence that the transversus perinsei has lost either its tonicity or its 
integrity. By placing the finger of the unemployed hand in the 
rectum and drawing the anus to one side, the muscle of the opposite 
side becomes tense if it be normal, and can be felt as a ridge deep in 
the posterior end of the fossa. When the fossa does not reach to the 
muscle the finger may detect its tense ridge by pressing into the cuta- 
neous surface of the perineum beside the anterior edge of the abducted 
sphincter ani. The transversus perinsei seems farthar back than 
normal, because the anterior edge of the sphincter is stretched forward 
by the rectal finger. When the perineal septum is relaxed the rectal 
finger may, if the vulva be pushed to the opposite side, detect the 
resistance of the muscle. Detection of the muscle in this way is a 
sign of a relaxed perineal septum. Complete relaxation of the trans- 
versus perinsei of only one side allows the sphincter ani to be drawn 
a little to the opposite side. 

Characteristics of the Perineal Body. 

Relaxation of the whole perineum, including the perineal septum, 
fasciae and connective tissue, is recognized by a sinking down and 
back of the perineal body, more particularly its anterior end or base, 

* These characteristics are best determined by palpation, and require no insoection. 



DIGITAL EVERSION OF THE VAGINA. 113 

so as to increase the projection below the external conjugate. The 
hymen, instead of being drawn up under the pubic arch, sags down 
and becomes more exposed posteriorly between the separated labia 
and is encountered before the ringer gets into the vaginal entrance. 
The fourchette projects but little above the surface un]ess the labia 
are stretched widely apart. The finger introduced into the rectum 
along its anterior wall, instead of being directed by the perineal body 
up behind the pubes, passes forward under or in front of the arch. 
Such relaxation, even when co-extant with a relaxation of the sphincter 
ani, is not necessarily occasioned by nor accompanied by any exten- 
sive lesion of tissue, and may be followed by a return of the parts to a 
normal condition. Fig. 30 represents a section of the perineal body 
thus relaxed. 

Rectal Palpation of the Perineal Body. 

The thickness of the perineal body is easily determined by the 
finger in the rectum, the thumb on the cutaneous surface, and the 
forefinger of the free hand on the vulvo-vaginal surface. Figs. 26 to 
30 show the shape of the tendinous portion, or that affording firm 
resistance to the touch. Straightening by tension (28 and 29), curving 
by relaxation (30), or loss of substance from injury, can thus be easily 
appreciated. The amount and firmness of connective tissue on the 
three sides is known by the amount and the resistance of the tissues 
over the tendinous raphe. The firmness of the structure as a whole 
can be approximately determined by drawing down, with the finger 
in the rectum, and thumb or finger of the other hand in the vaginal 
orifice, both together. The amount of resistance to such manoeuvres 
is by no means in proportion to the mere amount of the perineal 
body that may have been destroyed, as will be explained in discussing 
perineal ruptures. (See Chapter VII.) 

Digital Eversion of the Vagina. 

The finger introduced into the anus and passed palmar surface for- 
ward along the anterior rectal wall, comes in contact with the recto- 
vaginal septum at the recto-vaginal promontory, and can, with but 
slight inconvenience to the patient, evert the recto-vaginal angle of 
the perineal body, and lower end of the posterior vaginal wall, for 
inspection. This is particularly easy when the perineum is relaxed 
or lacerated. (See diagnosis of perineal lacerations, Chapter VII.) 



CHAPTEE IV. 

INSTRUMENTAL EXAMINATION OF THE FEMALE PELVIC ORGANS. 

Dr. Simpson recommended and practiced the use of the sound for 
the purpose of examining the uterus, and he has given to it a certain 
appropriate shape, size, and adjustment, which adds materially to its 
adaptability to this particular use. 

Object in Using the Sound or Probe. 

The main objects in examinations with the sound in such cases as 
I have now under consideration are, to measure the size and length 
of the cervical and uterine cavities, the mobility and position of the 
uterus, and, if need be, the connection of that organ with pelvic 
growths. At the present time a number of flexible sounds, or, more 
accurately speaking, probes have also been constructed for cases in 
which the alterations in size and shape of the uterine cavity render 
the larger and more rigid sound almost useless. 

Size and Length of Sound. 

It should be ten or twelve inches long, with one end fixed to a flat 
handle, and the other terminated with the ordinary probe point en- 
largement, about one-eighth of an inch in diameter. The wire behind 
the bulbous termination should be one line in diameter, round and 
smooth, and should gradually increase in size to the handle, where it 
might be about a quarter of an inch in diameter. The best material 
is copper, galvanized. 

Simpson's sound is larger and less flexible than Sims's, and is grad- 
uated or marked by notches, indicating inches. Jenks's flexible sound 

- - -sses the advantage of easily adapting itself to the shape of the 
uterine cavity. Fitch's measuring sound is less flexible than Jenks's, 
but has a similar sliding sheath for marking the depth of the uterus. 
Sims's small flexible silver probe and Thomas's whalebone sound are 
valuable substitutes for the heavier sound when we wish to explore a 
tortuous or very deep uterine cavity. 

cidents of serious character sometimes occur in using the probe 
in the uterus. Dr. Engelman, in the St. Louis Medical and Surgical 
Journal, says that he was present when Professor Carl Braun, of Vienna, 
pushed the uterine probe through the tissues of the uterus into the 
peritoneal cavity. Dr. Xoeggerath, of New York, mentions a case 
where the sound had been passed five inches, going through the fundus 



SIZE AND LENGTH OF SOUND. 



115 



uteri, as shown by the discovery of a cicatrix at a post-mortem exami- 
nation made several months afterwards. 

Other unquestionable instances of this accident are on record. Of 
these cases I have heard of none in which any untoward consequences 
followed what would seem to be at least a serious occurrence. As all 
the cases published were in the care of skilful and practical practi- 



FlG. 69. 



Fig. 70. 



Fig. 71. 



Fig, 72. 





Simpson's Sound. 



Sims's Sound. 



Jenks's Uterine 
Sound. 



Fitch's Measuring 
Sound. 



tioners, their occurrence must therefore be attributed to some other 
circumstance than rashness. The probability is that on account of 
disease the uterine structure had become too frail from attenuation or 
softening to resist the slight force used to introduce the probe. It is 
interesting as well as surprising that so little effect followed the forci- 



116 raSTRUMENTAX EXAMINATION OF FEMALE PELVIC ORG- AS*. 

ble entry of the probe to the uterine wall or the contents of the peri- 
toneal cavity. 

The Fallopian tube is sometimes so patulous from disease as to 
permit the sound to pass through it into the cavity of the peritoneum. 
Where the whole of the uterus is enlarged, as it is found for many 
days and sometimes weeks after parturition, the uterine orifice of the 
tube is large enough to admit the probe. This may be the case also 
from the enlargement caused by uterine catarrh. When the opening 
to the tube is thus enlarged it requires but a slight inclination of the 
uterus to one side of the pelvis to bring the Fallopian orifice in a 



Fig. 73. 




Introduction of the Uterine Sound, sh 



e handle '- 



direction to be easily entered by the instrument. When once it has 
entered the tube it will find no resistance to its farther progress. 

In a discussion before the Obstetrical Society of New York. January 
17th. 1871, reported in the Journal of Obstetrics of August. 1871, Drs. 
Budd, Thomas, and Xoeggerath, all speak of cases in which the sound 
seems to have entered the peritoneal cavity to a long distance through 
the Fallopian tube. 

Dr. Rosa Engert was kind enough to show me a case quite recently 
in which she repeatedly passed the sound through the Fallopian tube. 
When the end of the instrument had reached the fundus it required 



LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 117 

but little inclination to the left to cause it to enter the tube. The 
patient experienced no inconvenience from the examination. 

Another accident, and one of more importance because of its almost 
invariably fatal effects upon the -embryo, and also because of its more 
frequent occurrence, is the damage done sounding an impregnated 
uterus. 

Too great caution cannot be observed in making investigation of 
the condition of the uterus before passing the probe into its cavity. 
I have known two instances, however, in which the impregnated 
uterus was probed to a depth of several inches without interrupting 
gestation. When a suspicion of pregnancy exists, there can hardly 
be a circumstance so grave as to justify the use of the probe. 

In such cases we should unhesitatingly wait until time solves the 
question of pregnancy. 

The probe should not be used during menstruation, nor in the 
presence of great tenderness in or about the uterus. 

Mode of Using. 

After oiling the instrument, and introducing the index finger of the 
right hand, and placing it upon the os uteri, the sound may be carried 
along the palmar surface of the finger until the point arrives at the 
mouth of the uterus, when, by depressing the handle, its point may 
be carried forward into the cavity of the cervix. In order to insure 
its passage through the cavity of the cervix into the cavity of the 
body, the probe must be bent to the same degree as the male catheter. 
Great gentleness must be observed in the use of this instrument, be- 
cause it is an easy matter to do violence to the mucous membrane by 
a very little rudeness of management. After the sound has passed to 
the os internum, a sense of constriction is felt through the instrument, 
which feeling soon gives way, and the point then goes to the fundus 
without further resistance. 

Length of the Cervical and Uterine Cavities. 

The cervical cavity in the virgin is about an inch and a quarter in 
depth, and the cavity of the body from a half to three-quarters of 
an inch ; the former in the multipara is one and a half inches, and 
the latter an inch deep. In old age both are nearly or wholly oblit- 
erated. I do not often use the probe in this way for the examina- 
tion of the uterus in cases of inflammation and ulceration, but have 
adopted the suggestion of Professor Miller, of Louisville, and use it 
through the speculum, and shall consequently have more to say about 
it in connection with the use of that instrument. 

It often happens, with the present means, that there is great diffi- 
culty in determining the thickness of the uterine walls, and even the 



118 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

presence of a small growth in the anterior or posterior parietes. For 
the purpose of enabling the inexperienced to arrive at what, in many 
instances, is valuable information in this respect, I have devised what 
may be called the hysterometer, a cut of which is here given. It 
consists in the adaptation of two uterine probes to each other, with 
handles and scale for measurement, in such a way that one may be 

Fig. 74. 




The Hysterometer. 



introduced into the bladder, and the other into the rectum. Thus 
approximated on the uterus, as represented in Fig. 75, the handles 
and scale may be so arranged as to make the measurement. When 
this is done the instrument may be detached, withdrawn, and the 
exact thickness of the uterus is ascertained. If we wish to measure 
the posterior wall, one probe is introduced into the cavity of the 
uterus, and the other into the rectum, and the scale and handles ad- 



LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 



119 



justed, the measurement taken, and the instrument withdrawn. When 
the anterior wall is to be measured, one is introduced into the uterine 
cavity, and the other into the bladder. In this way, the length of the 
uterus and the thickness of the walls may be easily measured. 

This instrument will enable us to be much more accurate in our 
estimate of the shape of the uterus than any other means we can 
employ. The handles of the probes are adapted to each other by 
means of a slot, running from one end to the other, in one of the 
handles, while the other is of a size to fit into this slot closely and 



Fig. 75. 




The Method of Applying the Hysterometer for Measuring the Thickness of the Uterus. 



accurately. The scale is made movable, and may be easily adjusted 
after the probe portions of the instrument are in their proper place. 

In cases of distortion of the cavity of the uterus, or where there is 
a tumor to measure, the probes will be bent in different directions, 
until they adapt themselves to the shape of the parts. In consequence 
of the necessity of variance in the curvature of the probes in making- 
such measurements, the scale can serve only as an index to the rela- 
tive position of the two probes, and cannot be relied on for the exact 
size of any growth or other cause of thickness of the walls. After 



EPreTTRUMENTAIi EXAMINATION OF FEMALE PELVIC ORGANS. 

having adjusted the scale, therefore, and observing the figures, we 
must withdraw the instrument and readjust "by the scale, and then 
measure the distance between the points of the probes. This will 
give us the true measure. Often the instrument may be withdrawn 
without loosening it. which fact will facilitate the process very much. 
In cases : retroversion or retroflexion, when we wish to diagnos- 
ticate these replacements from a small tumor, which they sometimes 
very closely simulate, one of the probes in the bladder, so curve a - 
- : How downward and backward the anterior wall, the other in the 
uterine cavity, will clearly make out the difference. In like manner, 
only with reversed curves, and one probe in the rectum, the tumor 
may be diagnostic ■:-.:-> . i be present or absent. 



Speculum. 

Since the speculum has come into such general use. it has assumed 

a variety of shapes, and been 
composed of quite a number 
of different sorts of materials. 
For different purposes it is 
convenient, if not necessary. 
to be provided with diffei ent 
shapes, sizes, etc. ; but for or- 
dinary use we ought to have 
three different sizes: one 
small, one large, and the 
other of medium size. 
speculum and its modifications 



F:; 




Higby's Speculum. 

The bivalve, trivalve, and 
are the most - rul forms. 



_-::- "". 




■ 



3, nd different sizes of Higby's are popular instru- 
ment 



POSITION OF PATIENT FOR SPECULUM. 



121 



To aid us in getting a good view of the cervix, we may draw it into 
view, and, if necessary, depress it somewhat by the single or double 
tenaculum. 



Fig. 




Nelson's Speculum (closed). 



Fig. 80. 



Fig. 7 




Nelson's Tenaculum. 



Nelson's Speculum (open). 



Position of Patient for Speculum. 

To be prepared to use this instrument to the best advantage, our 
patient should be placed in the position I have heretofore describe^, 
viz., before a large window, through which as much daylight should 

Fig. 81. 




Double Tenaculum Forceps. 



be freely admitted as possible. The better light the better view, and 
unless we have plenty, we cannot be certain of correct results in our 



Fig. 82. 



Tenaculum Forceps. 

examinations. The bed and patient should be so placed that the light 
may fall straight through the instrument and full upon the parts at 



122 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

its internal extremity. We should also have some cotton-wool, sweet 
oil, and a couple of napkins, together with the dressing forceps I have 
before spoken of. 

Mode of Using the Speculum. 

In commencing the examination, we should oil our speculum, and 
our middle and index fingers. Sitting before the patient, we should 
introduce the index finger, and, if need be, the middle one also, to 
ascertain the position of the cervix uteri. This precaution will enable 
us to know in what direction, and how far, to introduce the speculum. 
After this preliminary examination, the forefinger and thumb of the 



fig. 83. 




peculum introduced {]/£}. 



left hand should be placed upon the edge of the labia, one upon each 
side, with which they should be gently separated ; and holding the 
speculum in the right hand, somewhat like a pen, we may introduce 
it by the guidance of the thumb and finger placed as above. In intro- 
ducing it, we should push it forward sufficiently to reach the cervix, 
and direct it upward, downward, or to one side, as we may have 
ascertained, by digital examination, to be the position of the os and 
cervix. 



HOW TO FIXD THE OS UTERI. 



123 



How to Find the Os Uteri. 

If we have not made digital examination, we may use our probe, 
and gently push the parts from one side to the other, turning the 
speculum in different directions until it is found. If the neck is too 
large to enter the speculum, we may spread the blades still more until 
it is brought into full view. Most frequently the parts are covered with 
some sort of secretion, and we should always, with cotton-wool or lint, 
with the dressing forceps, remove all of it, so that the naked mucous 
membrane alone presents itself to our view. Without this precaution, 



Fig. 84. 




Byford's Dressing Forceps. 



we may overlook an obvious and extensive ulceration ; for as the parts 
are covered over with this thick, opaque secretion, it either completely 
hides them from view or much modifies their appearance. I have 
often met with cases which I have observed attentively, for the pur- 
pose, if possible, of detecting ulcerations without this step, but failed, 
until the cotton was used, when extensive ulceration appeared. In- 
deed, I never think of coming to a conclusion of any kind by the use 

Fig. 85. 




Sims's Speculum. 



of the speculum without this precautionary measure. By this means 
we can see the color, size, shape, and some other conditions of the 
parts, and the color, consistence, and derivation of the secretions. 
When the mucus, pus, or blood comes from the mouth of the uterus, 
we can see it issuing from it. The shape and size of the neck and os 
of the uterus differ in different individuals, according as they have 
been impregnated or not. 

The late J. Marion Sims has instructed us in a different method of 
making examinations. He prefers a table. The patient is placed on 



124 INSTKTJMENTA1 EXAMINATION OF FEMALE PELVIC ORGANS. 

the left side, the left arm under and behind her, the legs strongly 
flexed upon the thighs, and these again upon the abdomen, while the 

FIG. 86. 




Sims's Depressor. 



Fig. 
(7> 



right knee is thrown forward, and over the left one on the table; 
this turns the patient over on the chest and partly on the 
abdomen. In this position his speculum is introduced by 
placing the forefinger of the right hand in the concavity of 
the extremity to be used, and the finger and instrument are 
introduced together. When well inserted, the perineum 
is drawn backward and the instrument is given to an 
assistant to retain in place. This will generally expose 
the cervix uteri completely ; but if it does not, the depressor 
is placed upon the anterior wall, and this latter is pressed 
out of the way, as represented in Fig. 92. Great freedom 
of examination is thus obtained in most cases. Still, if 
the os uteri is not seen plainly, it is seized with a tenacu- 
lum and drawn toward the external orifice. Many practi- 
tioners prefer this method of exposing the organ for all ordi- 
f~\ nary purposes of inspection and application. Dr. Emmet has 
I F modified the speculum of Dr. Sims by constructing it in a 
fashion that renders it self-retaining, and thus does away 
with the necessity of having an assistant. Many other self- 
retaining instruments have been invented, that answer an 
admirable purpose, among which I mention those of Pallen, 
of St. Louis, Xott, of Xew York, and Thomas, Hunter, 
Studley. Munde, Gillette, Erich, etc. Of course it is necessary 
to have the patient so placed that the light will fall into the 
dilated vagina and on the cervix. Dr. Sims drew the cervix down, 
when necessary, by means of a tenaculum : thus facilitating the 



F 



Tenac- 
ula. 



Fig. 88. 




Xott's Tenaculum Forceps. 



examination, and enabling the practitioner to make applications or 
operations upon it with much certainty. 



APPEARANCE OF THE OS AND CERVIX IN THE VIRGIN. 125 



Appearance of the Os and Cervix in the Virgin. 

The virgin uterus is small ; the cervical end is nearly round, and 
terminates in a truncated extremity. Through the speculum it does 

Fig. 89. 




alum, different sizes. 



not present the appearance of labial projections, and the os is either 
a small slit, about a quarter of an inch long, or a round opening into 



126 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

the middle of the truncated extremity. It is about large enough to 
admit with facility the end of a female catheter, and the neck projects, 
in relief, from the bottom of the parts exposed by the speculum, 
something like half an inch. 

Appearance of the Muciparous Uterus. 

The appearance of the multiparous uterus is quite different from 
this; the cervix terminates in labial projections, which divide its 
extremities into an anterior and posterior half, and it does not project 

Fig. 90. Fig. 91. 





Simon's Retractors. Lever for Dilating the Vagina from the Side. 

with so much prominence into the speculum. The os is represented 
by the cleft between these labial projections, and is large enough, in 
many instances, to admit the tip of the index finger. 

Appearance in the Aged. 

In the aged the labial projections seem to have atrophied to obliter- 
ation, and the speculum shows a round opening in a funnel-shaped 
depression, surrounded by the walls of the vagina. 



INDICATION OF MUCUS IN ABUNDANCE. 



127 



Exceptions to these Appearances. 

Although the above is an accurate description of these appearances 
under the different circumstances, there are many natural deviations 
from it. 

Color. 

The color of the mucous membrane covering the cervix, and enter- 
ing the os uteri, may be compared to that of the inside of the lips of 
the mouth, a pale rose-red. 

Appearance of Secretion. 

The parts are merely lubricated, not smeared or inundated, with 
mucus. There is just enough of this secretion to keep the membrane 

Fig. 92. 




This figure represents the Action of the Instruments in Sinas's method of Examining 

the Uterus. 

moist, but not enough to hide the surface from view. I speak now 
of the cervix uteri. 

Indication of Mucus in Abundance. 

An abundance of mucus must be regarded as an evidence of ex- 
citement ; its constant and persistent abundance as an evidence of 
disease. " Remember, that in spite of their name, it is not the busi- 
ness of mucous membranes to secrete mucus ; the more perfect their 
condition, the more favorable the surrounding circumstances, the less 
they do so. . . . The greater the diminution of their life, the greater 



128 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

the secretion." The more disease, the greater the secretion, until 
their integrity is destroyed, when the secretion becomes modified. 
The source whence this mucus is derived will show the point of dis- 
ease ; if it comes from the os uteri, the disease is in the cavity of the 
cervix or body of the uterus. 

Indication from Pus. 

It is extremely doubtful whether pus can be produced by a mucous 
membrane without destruction of the epithelium at least. Temporary 
congestion often increases the amount of mucus to be found in the 
vagina, but gives origin to no pus. The color of the mucous mem- 
brane, in cases of congestion, is a livid or a dark purple-red, instead 
of the scarlet of abrasive inflammation. 

Probe and Speculum Conjointly. 

When the neck of the uterus is exposed in the speculum, it will 
often be profitable to use the probe. If proper attention is paid to 
appearances under the use of the probe, much information may be 
gained. When the mucous membrane of the cavity of the cervix or 
body is inflamed, it is generally much more fragile than natural, so 
that it bleeds upon slight contact with the end of the probe. In cases 
where the inflammation extends to the cavity of the uterus, the probe 
passes the os internum without obstruction, and passes farther up 
than natural from the increased size of the cavity. 

Dilatation. 

By properly dilating it, we may subject the cavity of the uterus to 
a digital examination. Sufficient dilatation may be effected by the 
use of tents and dilating instruments made for the purpose. The 
compressed sponge, laminaria, tupelo, and slippery-elm tents are all 
employed as means of dilatation.' The sponge tents, as prepared and 
sold by instrument makers, are of various sizes and lengths. They 
are, or ought to be, perforated lengthwise, carbolized, and covered with 
a lubricant to facilitate their introduction. 

The sea-tangle or laminaria and the tupelo tents should also be of 
different sizes and lengths, smoothly polished, and very slightly taper- 
ing. All of these materials can be made in a flexed form to suit the 
curves of the uterus. When any of these tents are introduced in a 
dry state into the uterus, they absorb the moisture of its cavity and 
increase in size, and as they do so they dilate it. 

The sponge expands more rapidly than the tupelo or laminaria 
tents, and is less powerful in its dilating influence. There is not 
much difference in these respects between the tupelo and laminaria 



DILATATION. 



129 



tents. Perhaps the latter expand more strongly and act more power- 
fully, 

As the sponge dilates, it presents a rough surface to the mucous 
membrane, and to a considerable extent impairs its epithelial cover- 




Sponge Tents. 



ing. Serious inflammatory reaction has been known to follow the use 
of two or more sponge tents in immediate succession. The surface of 
the tupelo and laminaria tents do not become rough as they expand, 



Fig. 94. 



G 



;^ 



Laminaria Tent. 



and consequently are not as likely to be followed by injury to the 
mucous membrane. As the laminaria becomes moist it exudes a 
mucilage that serves as a protection to the mucous membrane. 



Fig. 95. 




Tupelo Dilators (hollow). 



Compressed slippery-elm bark makes a less powerful, yet very useful 
dilator. The solid tents made of this material expand to twice their 



130 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

diameter or more, in from one to two hours, when placed in the cervix 
— the hollow ones in much less time. Their rapid and comparatively 
safe action adapts them to office practice when we only seek for a 
moderate but rapid dilatation. When the cervico-uterine canal is 
tortuous, the smaller elm tents, whether curved or straight, may be 

Fig. 96. 




Compressed Slippery-elm Tents (straight and curved). 

rendered slightly flexible by being moistened and compressed between 
the blades of a dressing forceps so as to mash or break some of the 
fibres. 

All of these tents should be well secured by having a strong thread 
attached to them. This thread enables the patient or practitioner to 

Fig. 97. 



Compressed Slippery-elm Tent (hollow). 

remove them by simple traction, and does away with the necessity of 
the introduction of an instrument for that purpose. 

Tents intended to widely dilate the cervix, of whatever kind, should 
l>e introduced at the home of the patient, because perfect quietude in 
bed is one of the best measures to prevent the untoward effects some- 
times caused by the use of them. 

Sims's position is the most convenient for the introduction of the 
tent. In this position the cervix may be exposed by Sims's specu- 
lum, drawn slightly forward, and fixed by the uterine tenaculum or 



DILATATION, 



131 



a small vulsellum (Fig. 87). The tent, mounted on a tent-holder, 
or seized by the dressing forceps, is passed in until it has entered 
the os internum. The upper part of the vagina must be packed 
with cotton placed against the end of the tent, upon which it is 
made to rest, This will secure it in position, otherwise it might be 
more or less completely dislodged and thus fall short of its fullest 
effects. The first tent should be of a size that will permit it to pass 
easily into, and yet snugly fit the cervical cavity. If sponge, it will 
generally require about twelve hours to fully expand, and should the 



Fig. 



Fig 





Tent mounted on Tent-holder. 



Molesworth's Dilator. 



dilatation not be sufficient to admit the finger, the vagina and cervical 
cavity may be thoroughly cleansed with carbolized water, and a second 
sponge introduced in the same manner as the first, but surrounded by 
small slippery-elm tents. This second filling must be large enough to 
fill up the expanded cavity, and secured in the same way as the first. 
A somewhat longer time must be allowed if we use either of the other 
kinds, but the management of them is the same as that of the sponge. 
The wounded condition of the cervical mucous membrane caused by 
the sponge tent renders it very susceptible to inflammation, and calls 



132 INSTRUMENTAL EXAMINATION OF FEMAEE PELVIC ORGANS. 

for the strictest quiet and the avoidance of all co-operating morbific 
causes. The same condition favors the absorption of septic material, 
and thus exposes the patient to the danger of septicaemia. This can 
only be avoided by strict cleanliness. 

In using the tupelo and laminaria tents, the main danger consists 
in the liability to produce inflammation of the uterus, which may be 
propagated to the surrounding tissue, because of their very unyield- 
ing pressure upon the submucous structures of the organ. 

From these considerations the student will learn that the use of 
tents is fraught with much danger, and should not be resorted to 
except under such circumstances as seem to render them indispensable 
to correct diagnosis and a perfect course of treatment. The patient 
should be kept warm and in the recumbent position for several hours 
after a large dilating tent has been used. 

There are other means of dilating the uterine cavity, that in some 
cases may be resorted to with much advantage, especially when it is 
desirable to perform dilatation in a short time. 

Molesworth's dilator (Fig. 99) is one of the most simple and effective 
instruments for this purpose. The small-sized dilator may be made to 
enter the unimpregnated uterus, and when expanded by filling it with 

Fig. 100. 




Hanks' Dilators. 



water, under strong and gradually increasing pressure of the cylinder, 
it will, in favorable instances, open the cervical cavity sufficient to 
admit the second size. 

By succeeding one size with another I have, in less than an hour, 
been able to pass my finger into the cavity of the body. The uterus 
can also be dilated rapidly by hard rubber instruments, a very con- 
venient form of which is Hank's rapid dilators. 

The smallest size may be passed into the cervix by slow and gradu- 
ally increasing pressure. It may be succeeded by the second, and 
that by the third, and so on until the cavity will admit the finger. 

When the uterus is especially hard and undilatable, the gradual 
method, consisting of the use of tents, is the proper one to employ. 
When, however, the mouth of the cervix is softer and more yielding, 



EXPLORATORY CURETTING OF THE UTERUS. 133 

the rapid method is preferable, and in most cases Molesworth's is the 
instrument to be used. I would remind the student that great care 
is necessary to avoid damage from the use of any of these instruments 
or processes. 

The object in dilating the uterine cavity is to enable the sense of 
touch to discover its contents and condition. Sometimes, with the 
patient in the dorsal position, we may depress the uterus, by placing 
one hand above the symphysis, sufficiently to bring its cavity within 
reach of the finger; but usually it will be necessary to draw it down by 
a tenaculum or vulsellum until the finger will pass up to the fundus. 

Polypoid or submucous tumors, excrescences, and cancerous ulcera- 
tion may be discovered in this way when they could not be diagnosed 
with precision by any other method of examination. 



Exploratory Curetting of the Uterus. 

When it is inexpedient or undesirable to expand the uterine cavity 
sufficiently for the introduction of the finger (a procedure which re- 
quires considerable violence unless the uterus be enlarged), the dull 
curette may be used for its exploration. If fungosities, granulations, 

Fig. 101. 



Probe Curette. 



or otherwise disorganized mucous membrane exist, the dull curette 
will detach specimens for a microscopic examination ; if there be no 
such conditions the negative result will also be valuable. Thus, in 
cases of enlargement of the uterus with hemorrhage, when we are in 
doubt as to whether we have to deal with cancer, sarcoma, mucous 



Fig. 102. 






Thomas's Wire Curette. 



polypus, or an interstitial fibroid, the dislodgment of specimens gives 
evidence of the first three conditions, the absence of anything to be 
dislodged is of diagnostic value in the latter. 

A loop of bent copper wire with the ends twisted into a stem and 
covered with a small rubber tube may serve for this purpose. There 
is a dull curette in the market made to imitate a uterine probe bent 
at the end into a loop. Thomas's wire curette is also a very popular 
instrument. 

I have had one constructed something after the pattern of Sims's 
sharp curette, but perfectly dull, and quite strong, although flexible 



134 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

in the shank, with the end in view of being able to use considerable 
force without doing injury. We may obtain with it some information 
as to the size of the uterine cavity, the smoothness, roughness, or fria- 
bility of its mucous surface, and the firmness, sensitiveness, and con- 
tour of the uterine walls, and thus make of it a sort of substitute for 
the finger. A weaker shank would give unreliable information, while 
a finer loop might produce unpleasant or dangerous results. I con- 
sider this curette so safe when properly used, that I occasionally 
employ it in office diagnosis, but would be afraid to use any of the 
others with the same freedom. Two larger sizes are manufactured for 
(1) diseases involving enlargement of the uterus and (2) retained 
secun dines in abortion, which are more useful as therapeutic agents, 
but less so as diagnostic. A hollow compressed elm tent, Hanks' or 
Peaselee's dilators, or a flexible male bougie will sufficiently dilate 

Fig. 103. 




Byford's Finger Curette. 



the cervix in a few minutes for the smallest size, unless the uterus be 
too small to require exploratory curetting. A curette should not as a 
rule be used if there be much uterine or peri-uterine tenderness, nor 
during menstruation, nor during pregnancy. 

The Use of the Female Catheter. 

The female catheter usually passes in a slight curve backward and 
upward behind the pubis toward the neck of the bladder. When the 
urethra is dilated or sacculated the end of the catheter passes readily 
in almost any backward direction, and, instead of taking its own 
course into the bladder, must be carefully guided. In case of prolapse 
of the neck of the bladder the instrument passes back toward the 
recto-vaginal promontory away from the pubis. 

When the parts cannot or ought not to be exposed the catheter can 
be introduced by the touch. The index finger is placed along the 
urethral ridge between the urethral notches and drawn forward until 
the depression at its lower end, and just external to the pubic arch, 
corresponding to the meatus, is recognized, and the point of the cath- 
eter is slipped along the finger into it. Its withdrawal should be slow 



THE URETHRAL SPECULUM AND ENDOSCOPE. 135 

that the lower portion of the bladder may have time to be emptied. 
The ringer should be pressed over the mouth of the instrument as 
soon as the other end has passed out of the bladder into the urethra, 
for the purpose of retaining the last drops, and keeping them from 
running out on the bedclothes, and also of preventing the suction of 
air into the bladder by an inopportune inspiration or movement of 

Fig. 104. Fig. 105. 





Sims's Sigmoid Catheter, Self-retaining. Goodman-Skene's Self-Retaining Catheter. 

the patient. Winckel warns against depressing the outer end of the 
catheter too much for fear of the entrance of air-bubbles. 

Sims's sigmoid catheter (Fig. 104) and the Goodman-Skene's self- 
retaining catheter (Fig. 105) are useful when it becomes necessary to 
keep the bladder drained, as they remain in place. 

The Urethral Speculum and Endoscope. 

In rare instances it become necessary to inspect the mucous mem- 
brane of the bladder. The necessary dilatation of the urethra may 
be accomplished by using almost any of the uterine or urethral dila- 
tors to begin with, and the fingers afterward. (See "Palpation of the 
Interior of the Bladder," Chapter II.) The little finger can thus be 
got into the bladder without doing much damage. Dilatation, to the 
extent of admitting a large index finger, or Simon's largest dilator, 
has frequently been followed for a long time, sometimes permanently, 
by incontinence of urine. The way to avoid such an accident is to 
commence with small dilators, and dilate very gradually, consuming 
from half to one hour for the extreme dilatation. Incontinence has 
usually been the result of haste or carelessness. An anaesthetic must 
of course be administered. 

A small test-tube may be made to answer the purpose of a urethral 
speculum, and, with a small rhinoscopiq^mirror and reflector, also, of 
an endoscope for the inferior portion of the bladder. Skene, Barnes, 
A. R. Jackson, and others have invented special specula, but the 
dilated urethra can usually be pretty well inspected by stretching 
open the lower end with the finger or blades of a dressing forceps. 
Skene's endoscope is a valuable instrument for occasional use. By 
first distending the bladder with air, as recommended by Rutenberg, 
quite a satisfactory exploration can be made. Moderate distension of 
the bladder with air does not seem to add much to the danger of the 
examination, although it must be remembered that thorough instru- 



136 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

mental examinations of this kind are seldom entirely without danger. 
Moderate mucous irritation, and even inflammation, have frequently 
followed, cellulitis occasionally, and in two instances death. 

The mucous membrane of the collapsed bladder appears of a dirty 
grayish red through the endoscope, but when distended with air, a 
brighter red. The slits corresponding to the urethral orifices cannot 




Skene's Urethral Endoscope. 

usually be seen until entered by a probe or catheter. If the surface 
be wiped off and the walls of the bladder pressed so as to produce 
lateral traction, the trickling urine sometimes indicates the exact loca- 
tion of the orifices. 



Catheterization of the Ureters. 

Catheterization of the ureters was first performed by Simon* and 
after him by others. The object in view was usually to draw urine 



Fig. 108. 




Simon's Uretral Catheter. 



from one kidney for examination, in cases of suspected unilateral 
.yelitis and pyo-nephrosis. 

The uretral catheter is small, long and straight, with a longer and 
more gentle curve on the end than the female urethral. 



* Chirurgie der Nieren. 



CATHETERIZATION OF THE URETERS. 137 

There are four ways of catheterizing the ureter : 

1. By the vesical touch. 

2. By vaginal inspection. 

3. By vesical inspection. 

4. By the vaginal touch. 

1. Simon made use of the vesical touch through the dilated urethra. 
The inter-uretric ligament, which connects them, is one inch beyond 
the sharp border of the mouth of the bladder, and the uretral ori- 
fices about half an inch to either side of the median line. They are 
felt as slight elevations instead of depressions, over one of which the 
finger is laid as the catheter, guided by the touch, is pushed into it. 
(See Chapter II, Fig. 58.) The handle, or external end of the catheter 
must of course be raised and carried a little to the opposite side, as 
the ureter takes the diagonal direction. It is possible to pass it to the 
pelvis of the kidney.* 

2. Pawlickf exposes the anterior vaginal wall in the Sims's position, 
and introduces the uretral catheter under the direction of the eye. 
The upper end of the urethra is marked by a small prominence not 
far from an inch behind the meatus in the median line. From this 
prominence two diverging ridges run backward and are joined by 
slight furrows. The space thus included corresponds to the trigone 
at whose posterior angles the mouths of the ureters are to be sought. 
The catheter is introduced so that its end turns back against the base 
of the bladder and followed by the prominence it produces on the 
anterior vaginal wall. As the exact point of opening of the ureters is 
difficult to strike, he is careful to make the direction of the catheter 
correspond to the direction of the ureter, so that it will more easily slip 
into the minute orifice when it passes over it. A thorough knowledge 
of the anatomy of the parts, and considerable gynecological experience 
is necessary to execute this difficult although simple manoeuvre. The 
limitation of the motion of the catheter and the trickling of urine 
announce the successful passage. 

3. Inspection of the uretral orifice requires, of course, extreme dila- 
tation of the urethra and the introduction of a speculum into the 
bladder so as to bring the orifice of the ureter into view. The only, 
and the great, difficulty lies in getting a view of the orifice. Some- 
times the urine can be seen issuing from one ureter by pressing the 
speculum blade over the other. Arthur Lewer thus describes his 
method of exposing the orifices: J "The urethra is dilated; then one 
piece of Bryant's rectal speculum is passed along the urethra into the 

* For a more detailed account of the method see Winckel's Diseases of the Female 
Urethra and Bladder. 

f Archiv fur Gynekologie, vol. xviii. 



138 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

bladder and so placed that, seen from the front, it occupies one lateral 
half of the urethra and bladder beyond. When in this position the 
speculum divides the bladder into two compartments ; for example, 
supposing the speculum occupies the right lateral half of the urethra 
and bladder, then the orifice of the left ureter is in view." With the 
orifice in view the introduction of the catheter can be accomplished 
by sight. 

4. The simplest of all methods, however, is to find the interuretric 
ligament or else the junction of the ureter and the trigone by vaginal 
indagation, according to the methods explained in Chapter II. (Palpa- 
tion of the Ureters). The point of the catheter is then introduced into 
the bladder and turned down upon the trigone where it can be felt by 
the vaginal finger. With the end of the catheter on the vesical surface 
of the vesico-vaginal septum, and the finger on the vaginal, we should 
have but little trouble in getting the inter-uretric ligament between 
them, and tracing it to the uretral orifices, which are about an inch 
apart. The direction of the ureter having been determined by vaginal 
palpation, the catheter is given a corresponding direction, and guided 
as far as possible up the ureter by the vaginal finger. 

In attempting this manoeuvre for the first time an anaesthetic should 
be given, and great care be taken to keep the end of the slightly curved 
catheter upon the base of the bladder, and to avoid using force or 
poking about too freely. As the bladder walls yield to pressure there 
is some danger of thinking that the catheter or probe is a couple of 
inches up the ureter when it is only in the bladder, and of poking it 
into or through the walls or against inflamed pelvic tissues. It should 
be felt by the vaginal finger to pass under the broad ligament. 
Moderate dilatation of the urethra including the neck of the bladder 
renders the introduction easier. If folds of the bladder interfere, a 
few ounces of water may be injected into it. The end of the catheter, 
being on the finger, can be guided with great delicacy, and there is not 
so much danger of doing harm as in Pawlick's method, which requires 
either sufficient pressure upon the base of the bladder for the end of 
the instrument to produce a projection on the septum, or else a nice 
judgment in determining when the instrument arrives at the point in 
the bladder opposite that marked by the eye upon the vaginal wall; 
nor as in Simon's and Lewer's methods, which require considerable 
rough handling of the urethral walls. 

As it is hardly possible to catheterize or probe the ureter in every 
instance, it is better to desist after a few unsuccessful attempts, and 
wait for another opportunity. 

General Manner of Conducting an Examination in Making a Diagnosis. 

Having, from the history of the case, located the disease in some 
portion of the pelvis, and having determined that an examination 



GENERAL MANNER OF CONDUCTING AN EXAMINATION. 139 

must be made, we first resort to a digital exploration. If the rectum 
seems to be the seat of the trouble, we should put the patient on her 
side with the knees drawn up, and explore the rectum and if necessary 
the pelvic interior as much as possible through the anus. When the 
patient is a young virgin such an exploration maybe made to indicate 
where the disease resides, and sometimes may do away with the neces- 
sity of a vaginal examination. If, however, she have had previous 
vaginal examinations, or have borne children, and have symptoms 
that leave no doubt as to the existence of pelvic disease outside of the 
rectum, she should be put, preferably, in the dorsal position and exam- 
ined per vaginam. In the unmarried the finger will, in passing, recog- 
nize the condition of the hymen and amount of contraction of the 
orifices. In the childbearing woman it is sufficient at first to pass the 
finger slowly so as to be able to recognize the amount of relaxation or 
contraction of the orifices, sensitiveness or flabbiness of the mucous 
membrane and lower portions of the urethra and rectum. If extensive 
alteration be found the parts may be immediately inspected ; if not, 
the manipulations about the vulva are better left until the close of 
the examination, that irritation or contraction of the sensitive parts, 
as well as disagreeable impressions upon the patient, may not be pro- 
duced at the outset. My practice is to note the general condition of 
the vulvo-vaginal entrance as I introduce the finger, and to press the 
finger end into the tissues as I withdraw it after the palpation of the 
deeper structures, but to leave the inspection, vaginal eversion and 
grasping of the perineum between the fingers in the rectum and the 
others over the skin and vulvo-vaginal surface, until after the speculum 
is withdrawn. 

If a digital exploration through the rectum be desirable, it may be 
made as soon after the vaginal examination as the hands can be 
cleansed or after the speculum has been used. Examinations of the 
urethra should usually be delayed until toward the end, as they are 
apt to cause irritation and unnerve the patient. 

As the instrumental examination gives us but a small part of our 
information, it is well, before using it, to determine as nearly as possible 
the position and condition of each pelvic organ by the various forms 
of intra-pelvic and bimanual palpation. The probe or sound can 
seldom give us any accurate information as to the position of the 
organ unless the cervix is turned forward, or unless the uterus is fixed 
by adhesions; hence in ordinary cases I wait until I have exposed 
the os by the speculum before using it. The speculum usually turns 
the axis of the uterus so that the sound or probe may, unless con- 
tra-inclications exist, be introduced with safety until it meets with 
resistance. 

The experienced gynecologist can usually determine by the digital 
exploration the appearance to be presented through the speculum, and 



140 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. 

needs the instrument chiefly for treatment. The general practitioner 
will require it, however, to diagnose the amount and character of 
uterine ulceration and congestion and the discharge. The character of 
ulceration, whether simple erosion, granulating or dissecting; the 
color, whether normal, pale, dark red or dark blue; the shape of the 
os and labia, and position of deposits or enlargements, etc., should be 
accurately noticed. 

The condition of the vaginal raucous membrane should also be noted. 

In pregnancy and in some cases of pelvic disease it is altered in 
color to correspond with the cervix. In cases of uterine disease it is 
altered in color either independent of the cervix, or is not altered as 
much as the cervix, if at all. 

An examination of the interior of the bladder, or a dilatation of the 
uterine cavity, or in fact any long-continued manipulation, should 
be avoided if possible at a first examination, or at the office. Our 
endeavor must be to benefit the patient, and to do that we should 
study to avoid doing any harm. For particulars as to examinations 
see Chapters II. and III. 



CHAPTER V. 

DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

Adhesion of the labia, and consequent occlusion of the vagina, 
sometimes occurs in infancy, or early childhood, as well as in adult 
life. The adhesions of infancy are so feeble and easily broken up, 
that they may be considered a trifling affair. Upon examining the 
parts, it will be found that there is no development of adhesive tissue, 
but the mucous membrane of the two sides is merely glued together 
by the mucus accumulating and drying between the parts, when in 
close contact, from want of cleanliness. The vaginal orifice is closed up 
to the urethra above, and down to the fourchette below. The treat- 
ment consists in separating the labia, by forcibly pressing each in 
opposite directions, until the adhesion gives way, and washing and 
oiling them once a day afterwards to keep them from adhering again. 
Should we not be able to separate them in this wajr, the point of a 
silver catheter may be passed down so as to effect it. There will be no 
need of any other instruments in the case. 

On one or two occasions I have seen firm tissual cohesions of the 
labia in childhood as the effect of ulcerative vulvar inflammation. 
This form of adhesions may be so firm as to require the use of the 
knife. They are, however, always superficial, and we may generally 
introduce a bent probe or director behind the adhesions from above. 
When this is the case, it is, I believe, the best plan to separate them, 
by drawing the bent director through the adherent part. The same 
care as in the infant will prevent them from adhering again. 

The most grave labial adhesions we meet are in the adult, as the 
effect of neglected inflammation of the vulva after childbirth. They 
may entirely close the vaginal orifice by the coaptation of the entire 
inner surfaces of the labia. I have met with more than one instance 
in which the hairy margins of the labia were so nicely adjusted to each 
other, that it was difficult to distinguish the point of original separa- 
tion, from the posterior commissure to the urethral orifice, and the 
finest probe would not reach the vagina anywhere. The depth of the 
adhesion may be very great, involving much of the vaginal cavity. 

These cases are very embarrassing, and are seldom perfectly reme- 
died. It is decidedly the best plan not to interfere with them until 
the menstrual accumulation fills up all the vaginal cavity remaining 
inadherent, and then our object should be to reach the accumulation 
with a small trocar as near the middle of the adherent parts as pos- 
sible. Placing our patient in the lithotomy position, the catheter 



142 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

should he introduced into the urethra, the urine all drawn off, and the 
urethra held as near the symphysis pubis, or as far from the middle 
line of the vagina, as practicable. The catheter should be thus held 
by an assistant, while the forefinger of the left hand should be placed 
in the rectum. With this preparation we may safely introduce the 
trocar into the collection of fluid as felt by the finger. The fluid being 
drawn off, the outer extremity of the perforation may be increased by 
laceration as far as may be desired, and as deeply as the surgeon 
may consider it safe. The whole cavity should be thoroughly 
cleansed by a syringe with soap and water and the opening may be 
maintained by a glass plug. If the opening is superficial, the treat- 
ment will not be protracted ; but if it is deep, it will be tedious. It 
should be continued until all danger of closure is past, and it will be 
best to keep the patient under our supervision for sometime after this 
appears to be the case. 

Wounds. 

The labia are sometimes wounded by external violence and some- 
times torn during labor. When the wound is deep enough to reach 
the bulb of the clitoris, alarming and sometimes fatal hemorrhage is 
the result. Professor Meigs gives an instance of great hemorrhage 
from these parts in a woman who had fallen upon a chair so as to cut 
through one of the labia. A case of fatal hemorrhage was caused 
in this city about four years since, in the following manner, as well as 
it could be learned from a legal investigation : A drunken husband 
returned home late at night, and, as was his wont under such circum- 
stances, beat and kicked his wife, who was probably also inebriated. 
He kicked her with great violence in the genitals, and the square-toed 
heavy boot, in penetrating the pelvis, had cut off one labium and 
deeply wounded the other. In six or eight hours after the occurrence 
the woman was found dead, with such copious effusion of blood from 
the wounds as, in the opinion of the examining jury, to account for the 
fatal result. I saw a case many years ago, where the patient was 
wounded by a knife in one labium so as to cause very profuse hem- 
orrhage. 

As hemorrhage is the important effect of these wounds, our efforts 
should be directed to its suppression. The bleeding part should be 
pressed by the hand firmly against the pubic ramus of the side upon 
which it is situated until temporarily arrested, when an elastic 
air-bag or plug of oiled cotton or lint may be introduced to fill up the 
vagina, and a hard compress placed and held firmly by bandages, so 
as to press the wounded part between the two. When wounds of the 
labia are large and gaping, the hair should be removed, and the wound 
treated according to ordinary rules for external wounds. The rents 
occurring in labor do not, in the great majority of cases, require any 
special treatment, cleanliness and quiet being all that is required. 



VAEICES OF THE LABIA AND VULVA. 143 



Sanguineous Infiltration. 

During labor, when the parts are stretched to their utmost extent, 
some of the arterial twigs occasionally give way and extravasate the 
blood in the loose structure of one labium. The infiltration usually 
shows itself after the child has been delivered; but sometimes, before 
the head has passed, the swelling becomes very great, and proves 
an obstacle to its expulsion. When this last is the case, the blood 
is effused from a large branch of the pubic artery, and the forcible 
injection into the tissues is so extensive as to fill a large part of the 
space between the vagina and the pelvic walls. This is a very seri- 
ous state of affairs, and calls for prompt and judicious interference. 
I once saw, in consultation, a case of this kind, so extensive as to ar- 
rest labor for several hours. These effusions, however, do not always 
call for surgical treatment, but when, as in the case here alluded to, 
the effusion is extensive, we must make a free incision in the inner 
surface of the labium and allow the blood to escape ; if it is coagulated, 
we should introduce the fingers and dislodge it. Water- dressing, some 
evaporating lotion or cooling discutient will be sufficient, and absorb- 
tion will be effected in from one to four weeks. Suppuration occasion- 
ally, I think not frequently, is excited by a small amount of effusion. 
This should be treated as an abscess. If the amount of blood is great 
and the parts are tensely distended even after the child is expelled, it 
is better to liberate it by incision, for fear of sloughing or extensive 
suppuration and serious damage. 

Varices of the Labia and Vulva. 

This condition of the vulva may be of greater or less extent. Gen- 
erally the varicosities are scattered about on the inner side of the 
greater labia ; sometimes only one or two exist of any size, but occa- 
sionally one labium is permeated by large blue veins in every direc- 
tion until they seem to have almost entirely replaced the other tissue. 

When the venous enlargement is great there is danger of rupture 
and profuse hemorrhage, even enough to bring about fatal results. 
The veins are especially large during pregnancy, and if wounded re- 
quire prompt and energetic treatment. For the emergency, pressure 
on the point of rupture will enable us to immediately arrest the 
hemorrhage. The ligature, however, will be necessary to secure the 
patient from an immediate repetition of the accident. This should 
be applied so as to completely control the loss. The radical cure re- 
quires the obliteration of the veins, effected in the same manner as 
elsewhere, by injection with the persulphate of iron, ligating with or 
without pins, etc. A radical cure should never be attempted in the 
absence of pregnancy, unless demanded by some great emergency.. 



144 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

(Edema. 

The distensible nature of the structure of the labia renders them 
liable to great ©edematous infiltration in cases of general dropsy. 
Ordinarily, such distension is a matter of trifling importance, but the 
supervention of labor at a time when they are very largely swollen is 
often an embarrassing condition. They are sometimes so swollen as 
to occlude the vaginal entrance, and yield only after protracted efforts, 
and even then, sometimes, only after one of them has been more or 
less torn. When excessive oedema is discovered before the head 
presses upon the external parts, or even then, no time should be lost 
in taking measures to lessen their size. This may be best done by 
everting first one and then the other, and making from ten to twenty 
small punctures through the mucous membrane only. A very sharp- 
pointed knife, taken between the thumb and finger of the right hand, 
so as to show only about the eighth of an inch, is the best instrument. 
Several quick, smart strokes with the instrument thus held, suffice for 
the operation. The serum exudes from the punctures, and in half an 
hour the swelling is very much reduced. 

Phlegmon. 

Abscesses in the labia are apt to occur in three different forms. The 
first is common phlegmonous inflammation, occurring in the central 
part of one labium, very rarely in both. The heat, swelling, and pain 
are very great, and the inflammation runs its course quite rapidly, 
generally suppurating and discharging in from six to eight days. This 
form of inflammation results from bruises, acrid discharges from the 
vagina, or the extension of inflammation from that cavity. It is lo- 
cated about the centre of the labium, and the swelling and tenderness 
are great from the beginning. The second form originates in overdis- 
tension of Duverney's gland, from a stoppage of its excretory duct. 
It is situated deeply at the lower or posterior end of the labium, and 
generally more slow in its progress. If the patient is intelligent, and 
has observed the case with care, she will tell us that there was a little 
tumor in the seat of disease for several days, sometimes weeks, slightly 
tender at first, but gradually becoming more so until the abscess was 
fully formed. In this stage the labium is enlarged, tender, and hot, 
but there is not the acuteness of inflammation that is seen in the first 
variety. If the surgeon has an opportunity to examine the parts 
during the progress, he will perceive a well-defined tumor, pyriform in 
shape, with the small extremity directed to the vulva, while the larger 
passes beneath the ramus of the ischium. It will not seem to be, as it 
is not, in the central part of the labium, but beneath its under surface. 
It will bear handling somewhat freely, and by pressing against the 
.ramus, and directing the pressure toward the vulvar end of it, the con- 



PHLEGMON. 145 

tents may sometimes be pressed out. The contents in the early stages 
are, for the most part, mucus. If examined later, the surrounding 
parts, and the labium particularly, will be found in a state of phleg- 
monous inflammation, which, in ten days or two weeks, suppurates, 
and the pus is evacuated spontaneously. In this form of inflammation, 
if the duct of the gland can be opened before the inflammation becomes 
considerable, suppuration may be avoided. This may be done by 
pressing the fluid out, or introducing a very small probe into the canal 
of the gland, thus opening it. If these are both impracticable, it is 
better to puncture it and squeeze the contents through the outlet thus 
made. If inflammation has begun, we may treat it like the former 
variety, with leeches, purgatives, evaporating lotions, etc., in the earlier 
period, and afterwards by poultices and anodynes until the suppura- 
tion is complete, when it should be evacuated by puncturing it on the 
mucous surface of the labium. The third variety is characterized by a 
succession of small furunculi. They first show themselves as small 
points of induration immediately below the mucous membrane or 
skin, are very tender, and in the course of a few days suppurate. One 
scarcely passes through these stages before it is succeeded by another, 
and thus a continuation of them prolongs the march for weeks, and 
even months, before they cease to return. This condition has existed 
only in such of my patients as were the subjects of some form of ute- 
rine disease, attended with leucorrhcea. They are generally anemic, 
constipated and dyspeptic. The radical treatment consists in curing 
the disease of the uterus, correcting the state of the bowels by mer- 
curial and saline cathartics, and reinvigorating the patient by the ju- 
dicious employment of tonics. We may palliate the sufferings of the 
patient by cleanliness, as bathing the parts thoroughly several times a 
day with pure cold water, and using cold-water injections per vaginam, 
and making such application to every hardened point as soon as it 
shows itself as will arrest its progress. I have used successfully the 
strong tincture of iodine applied to the part, and the solid nitrate of 
silver. If either of these applications is used as soon as the inflamma- 
tion begins, it will sometimes be arrested, and the patient escape for 
several days, or until another furuncle begins to form. Should we be 
unable to thus cut short the inflammation, we must use poultices of 
bread mixed with a solution of acetate of lead, and anodynes, until 
suppuration is perfect. These small points of suppuration usually 
break themselves, and they will seldom be lanced. Notwithstanding 
the fact that inflammation of the labia is very painful, the patient will 
in almost all cases bear her distress until suppuration is complete, or 
at least unavoidable, so that our treatment is generally confined to 
that appropriate to the suppurative stage. The whole process of 
inflammation is rapid, and this may be an additional reason why the 
first stage is not the subject of observation. 

10 



146 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

Abscesses of the Labia 

Sometimes become chronic, especially such as find their origin in 
Huguier's gland. An interesting case of this kind is recorded in the 
Gynecological Journal of Boston, second vol., p. 136, by Dr. H. R. 
Storer : 

" For many years the lady had found coitus almost impossible, owing to occlusion 
of vulval opening by lateral pressure. She was now several months pregnant, and the 
labial tumor was rapidly increasing. The tumor was very irregular in outline, with 
lobulations and depressions such as might easily have been occasioned by convolutions 
of intestine within a thin hernial sac. There were present many symptoms of strangu- 
lated hernia, and the patient's distress and local suffering were extreme. It was im- 
possible, by the most careful examination, to make a positive differential diagnosis 
though Dr. Storer was strongly inclined to believe it was a labial abscess of many 
years' standing, taking its rise from inflammatory obliteration of the duct of Huguier's 
gland. He cut carefully down upon the most presenting portion of the tumor, and 
obtained a free discharge of fetid pus. The sac was treated by carbolized tents, and 
the patient made a rapid recovery." 

Labial abscesses become chronic in another way ; the duct of Hu- 
guier's gland becomes obliterated; an abscess and discharge of pus 
take place by spontaneous eruption ; the opening closes, and this is 
followed by reaccumulation, rupture, etc., and this is repeated for an 
indefinite length of time. This form of chronic abscess is best treated 
by laying the sac open freely and emptying at once, or keeping it open 
until the contents are evacuated, and then every second or third day 
injecting a solution of nitrate of silver or tincture of iodine, or some 
other irritant that will awaken granular inflammation in the lining 
membrane of the sac. This kind of treatment should be persevered 
in until the cavity is obliterated completely. 

Labial Hydrocele. 

A collection of serum sometimes found in the labium of the female 
has received the denomination of hydrocele, suggestive of its simi- 
larity to dropsy of the scrotal cavity. The serous fluid occupies two 
different positions in the labial structures. In some persons the peri- 
toneum is protruded through the inguinal rings and down into the 
upper portion of the labium. In the pouch formed by this descent of 
the peritoneal membrane, serum sometimes collects in considerable 
quantity, and when adhesion at the external ring takes place it be- 
comes confined. Thus an ovoid tumor is found with one end at the 
external ring, and the other extending more or less in the upper part 
of the labium. When filled to great tension it becomes to a consider- 
able extent translucent and very firm. I have seen two of these tumors 
decidedly larger than a hen's egg. As this protrusion is abnormal the 
tumor is very rare. Winckel in his new book on gynecology says it 
.8 oftener seen in the right side and very seldom on both sides. 



LABIAL TUMORS — HYPERTROPHIE1) LABIA. J 47 

But another tumor receiving the same appellation is developed lower 
down in the labial structures, and occupies the imperfect cavity in the 
substance of the labium formed by the prolongations of the two layers 
of the superficial fascia of the abdomen. Between these layers is a 
large amount of loose cellular tissue into which serum may be infil- 
trated in such quantities as to give rise to quite a large tumor. This 
tumor lies deeper in the substance of the labium and is farther re- 
moved from the external ring than the others. It distends the whole 
labium, enlarging in every direction, and sometimes overrides the 
labial fissure so as to give the patient much inconvenience. 

The diagnosis of these collections is usually not difficult. They are 
slow of growth, unaccompanied by evidence of inflammation, and of 
little importance in any other respect than by reason of their bulk. 
The upper one is pronounced, and, unlike hernia, it cannot be returned 
into the abdominal cavity. When the patient coughs it does not re- 
ceive the abdominal impulse as does hernia. The lower one is distin- 
guished from the upper by its more spherical shape and the fact that 
it does not approach the inguinal ring as closely as the upper one. 

They can generally be promptly cured by incising them freely, in- 
serting a small drainage tube, and washing out the cavity daily. 
Eight or ten days will usually suffice to induce a granulating condi- 
tion that will destroy the secreting character of the cavity and finally 
obliterate it. If the patient is kept quiet there need be no apprehen- 
sion of unfavorable conditions. 

Labial Tumors 

Do not differ in any important respects from those observed in other 
parts of the body. In structure they may be fibrous, fatty, or encysted 
fluid. The latter kind I have met with more frequently than either 
of the others. The fibrous are next in frequency, and the fatty per- 
haps least. In no respect does the treatment differ from the treatment 
of the same kind of tumors elsewhere. They should be dissected out 
thoroughly, no portion of tumor or cyst being left behind from which 
to be reproduced. The vulvo-vaginal gland is occasionally developed 
into a cystic tumor by the closure of the duct through which its con- 
tents are evacuated. This and the other forms of encysted tumors of 
the labia may be treated by evacuation and stimulating injections 
until the sac is obliterated. 

Hypertrophied Labia. 

The labia are sometimes hypertrophied, without much alteration of 
structure, to such a degree as to become cumbersome and troublesome, 
requiring amputation. This may be done by the knife or ecraseur 
according to the shape and size of the superfluous part. 



148 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. 

These organs are very rarely the seat of elephantiasis, Fig. 109 (Scan- 
zoni). They sometimes are enlarged by this disease to an enormous size, 
extending down to the knees, as shown in the figure taken from Scanzoni. 
If we meet with this affection before it has involved too much of the 
substance of the parts to be completely excised, we are justified in re- 
moving it ; but if the skin on the thighs or abdomen is affected, so as 

Fig. 109. 




Elephantiasis of the Labia.— From Scanzoni's Diseases of Women. 

to require extensive and dangerous dissection, we should not operate 
for this purpose, but content ourselves by palliative treatment, clean- 
liness, anodyne lotions, etc. It should be remembered while consid- 
ering the propriety of removing small tumors of this kind that they 
very often return and resist every species of treatment. 



CANCER OF THE LABIA. 



149 



Cancer of the Labia 

Is not of unfrequent occurrence. I have only seen the epithelial 
variety in this locality. Two cases have come under my observation 
within three years. The last one was a Scotch woman fifty-one years of 
age. The disease was located on the left side. When I first saw it the 
whole left labium (Fig. 110) presented an appearance so similar to 
a case illustrated in Dr. McClintock's work on women, that I have 
availed myself of that figure. In my patient the disease was on the 
opposite side. When the disease has not advanced so far but that it 



Fig. no. 




Cancer of the Labia.— McClintock. 



may all be removed, we are justified in excising it. We should be 
very particular to remove all the morbid substance. Scirrhus probably 
very rarely invades the labia majora. Dr. McClintock gives one case 
only. It does not appea,r that other authors have often met with it. 
The soft or fungoid variety seems to occur with even less frequency 
than the hard form of cancer. Cancer of the labia is attended with 
similar symptoms, and presents the same appearances that it does in 
other organs. I need not stop to give it more attention in this place. 
Absence of the labia is very rarely observed. 



CHAPTER VI. 

DISEASES OF THE VULVA. 

Condylomata of the Vulva. 

Warty excrescences in great variety make the vulva the seat of 
their growth. They are often flat, smooth elevations, small usually, 
but sometimes as large as filberts, isolated or congregated. Sometimes 
they are sparsely scattered over the cutaneous surface of the labia and 
the mucous covering of the vulva, but not unfrequently they are 
thickly crowded together, with deep fissures between them and exco- 
riations on their surfaces, that give origin to acrid sanious discharges, 
which excoriate the neighboring skin and soil the linen. The smell 
from this sanious discharge is sometimes very offensive. These excres- 
cences are not always smooth and rounded even when isolated, but oc- 
casionally are rough and ragged, and in a few instances those spring- 
ing from the margin of the vagina are arborescent, slender, and from 
half an inch to an inch in length. We again find them yellow, flat and 
fragile. In most instances these growths are confined to the vulva and 
labia, but sometimes they cover a large part, if not the whole of the 
mucous membrane of the vagina and cervix uteri. I saw a case quite 
recently in which arborescent excrescences — many of which were three- 
fourths of an inch in length — sprang from the whole of the vaginal mu- 
cous membrane. This patient was pregnant by a syphilitic husband. 

The cause of these growths appears to be the syphilitic taint. So 
far as I now remember all observers agree that syphilis is the only 
cause of them. 

Treatment. 

We may very properly trust the alterative course calculated to 
remove the syphilism under which our patient is laboring for the 
relief of the milder forms of these excrescences, and we should not 
fail to institute alterative treatment for even the more harassing vari- 
eties ; but in many cases we will relieve the patient more readily by 
removing a part or the whole of the larger growths with scissors, and 
afterwards dressing the wounded surfaces with mercurial ointment. 

Inflammations. 

Erythematous, papular j vesicular, and pustular inflammations of the vulva 
are not unfrequently observed, as are also squamous diseases. They 
resemble the same form of disease in other muco-cutaneous cavities 
and the skin, and hence will not here claim a separate description. A 



INFLAMMATIONS. 151 

disease somewhat more distinctive, however, and yet resembling a dis- 
ease of the month, is known as purulent vulvitis. This affection is 
characterized by severe inflammation of the mncous membrane of the 
vulva, attended with minute points of ulceration, numbering from 
one to two dozen. The ulcers are small, an eighth of an inch in diame- 
ter, slightly excavated, and almost always covered with pus. The 
vulva is intensely red, and bathed in pus and mucus. The inflam- 
mation sometimes extends into the vagina and causes a copious flow 
of pus and mucus from that cavity. Not unfrequently the labia are 
very much swollen, and occasionally the deeper tissues are involved 
in phlegmonous inflammation. This form of inflammation is not 
unfrequently, in its early stages, attended with considerable febrile 
excitement. To a superficial observer it strongly resembles gonorrhoea, 
from the swollen labia, burning pain, copious muco-purulent discharge, 
and the difficult and painful micturition. Its occasional sudden and 
unexpected development adds to this similitude, and legal proceed- 
ings have been instituted against parties supposed to have been in- 
strumental in imparting the disease to little girls. It occurs in children 
generally from two to ten or twelve years of age, and probably results 
from want of cleanliness, heat, and local irritants accidentally applied. 
If allowed to pursue its course undisturbed by treatment, other than 
cleanliness, it will generally subside spontaneously in two or three 
weeks, or in the course of that time become very much subdued, and 
run into chronic inflammation without ulceration. This last is often 
extended into adolescence, and, as vaginitis, gives origin to the leucor- 
rhcea of girlhood, and finally to the endometritis of the woman. It 
sometimes attends upon a debilitated and scrofulous constitution, and 
is complicated with indigestion, constipation, and ascarides ; but it is 
not likely originated, though aggravated and fostered, by these atten- 
dant circumstances. 

Treatment. 

The treatment is general and local. In the beginning, where the 
inflammation is high, it should be antiphlogistic and soothing. We 
may administer a mercurial cathartic, and quicken its action by a 
saline laxative, and after the bowels have been thoroughly moved, 
nitrate of potassa may be given internally, every three or four hours, 
in doses to suit the age of the patient. The parts should be frequently 
bathed or fomented with a decoction of poppy-heads, or with the 
watery extract of opium. In the course of four or five days the acute 
symptoms will begin to subside, when, in addition to attention to the 
bowels, we may administer an acid solution of quinine internally, and 
begin the use of astringents locally. A solution of tannin, sulphate 
of zinc, acetate of lead, or other astringent, weak at first, and after- 
wards increased in strength, may be applied freely to the parts four or 



152 DISEASES OF THE VULVA. 

five times a day. These remedies will generally remove the inflam- 
mation in a reasonable time. The astringent should be increased in 
strength to a sufficient degree for the purpose. If those mentioned 
are not strong enough, the chloride of zinc, sulphate of copper, or 
even nitrate of silver, may be very properly resorted to. Should the 
inflammation extend into the vagina, the astringent may be injected into 
that cavity by means of a small hard-rubber syringe. AVe ought to 
be careful to use a very small syringe, and not to introduce it too far. 
The nurse should be carefully instructed in this kind of application. 
I feel impelled to insist upon the complete removal of the inflamma- 
tion as early as it can reasonably be done, believing that if it continues 
until puberty, the inflammation extends into the body of the develop- 
ing uterus, and entails a very distressing train of suffering upon the 
patient, that might have been avoided by an early and complete cure 
of the vaginitis. I am persuaded that too much importance cannot 
be attached to these views. 

Follicular Vulvitis. 

Inflammation of the vulva, instead of affecting the mucous mem- 
brane, as in the purulent form, is sometimes confined to the follicles 
and glands of the vulva. In this form of the disease minute papil- 
lary elevations on the mucous surface of the labia majora. the nym- 
phse, the prepuce of the clitoris, and elsewhere in the orifice of the 
vagina are first observed. These increase in size and become red, 
while the intervening mucous membrane is often very much inflamed. 
In many instances a number of these elevations become pustules, 
their bases hardened, red, and very tender. Oftener there is only a 
copious flow of mucus stained with pus-corpuscles from the follicles. 
The acute form will generally run its course and subside in a few 
weeks, sometimes in from ten to twenty days. But follicular vulvitis 
occasionally becomes chronic, and then is exceedingly obstinate and 
difficult of cure. 

Causes. 

Want of cleanliness, vaginitis, pregnancy, and malignant affections 
of the vagina and uterus are the most frequent causes. 

Treatment. 

The treatment should be rest in the recumbent posture, alterative and 
saline cathartics, cleanliness, first emollient poultices, and afterwards 
astringent washes and applications. If the patient be debilitated, the 
bitter tonics, quinine especially, will be found useful. The subjects 
of this form of vulvitis generally require supporting and tonic treat- 
ment. When the secretions are offensive, carbolized glycerin should 
be freely applied, two or three times a day. 



PRURITUS PUDENDI. 153 

"When it is chronic, there will be necessity for the use of stimulants 
so strong as to modify the inflammation. Nitrate of silver in substance 
applied once in seven or eight days to the whole of the inflamed sur- 
face will sometimes cause the disease to yield. In connection with 
this glycerin, with tannic acid dissolved in it, or impregnated with 
creasote, may be used between the applications. 

Alteratives are often found to be very beneficial. Iodide of potas- 
sium, sarsaparilla, stillingia, and, in plethoric patients, mercury are 
the ones on which most reliance may be placed. 

Dr. Thomas speaks of having made a cure by " dissecting off the 
whole mucous membrane lining the vulva." 

Pruritus Pudendi. 

A very annoying and often obstinate affection of the genital organs 
is an inordinate itching of the vulva. The itching returns in paroxysms. 
The patient may be free from it except when standing by a warm fire, 
or when heated by exercise, passion, etc. Or she may be affected 
only at or near the menstrual period. Again, the paroxysms return 
without any apparent cause. In one variety of the disease the sensa- 
tion sometimes is that of a burning glow, attended with an irresistible 
desire to rub or scratch the parts, a desire which the most delicate 
sense of propriety cannot always keep within due bounds. In another 
the sensation is such as might be produced by the crawling of pediculi, 
and the patient is sure that thousands of these insects are moving 
upon her person, and will be convinced to the contrary only by in- 
spection. This feeling of formication, although very disagreeable, is 
a slight inconvenience compared to the sufferings of the other variety. 

The former variety is almost always attended with inflammation of 
the mucous membrane of the vulva. The accompanying inflammation 
may be simply erythematous, papular, or vesicular. Dr. Dewees 
describes a variety of vesicular inflammation resembling aphtha, 
attended with pruritus. I am sure that neither the papulae nor vesiculae 
are always present in very distressing cases, although I have not seen 
this affection when the parts were not in some way inflamed. It may 
be observed that, in the formication variety of pruritus, the itching is 
generally in great part if not wholly confined to the cutaneous surface 
of the labia. It will be inferred that I consider pruritus but a symptom 
of several diseased conditions, generally of the genital organs but 
sometimes undoubtedly caused by irritation in the intestinal tube, 
particularly the rectum, or by some other remote cause. An intelligent 
scrutiny of the cases as they arise will most frequently result in the 
discovery of the originating condition. It is often an obstinate affec- 
tion, lasting in bad cases for weeks, months, and even years, but more 
frequently it is amenable to a judicious course of treatment. 



154 DISEASES OF THE VULVA. 

Treatment. 

The first thing to be done is to remove the cause, when practicable. 
In order to do this, the abdominal organs will require attention. 
The sluggish secretions and bowels must be corrected by alteratives 
and laxatives. A mercurial, say five grains of blue pill, may be given 
at. night, to be followed in the morning by a saline laxative, sufficient 
to cause one or two stools. This may be repeated at intervals of from 
one to four days, until the object is gained. Meantime, if the stomach 
is weak and digestion imperfect, the bitter infusions, with alkalies or 
acids, as the condition may require, will be demanded ; and should 
the patient be anaemic, iron may be given. Sometimes the patient 
will be plethoric, when the alteratives, with spare diet, will do better. 
With the above treatment, if the health be faulty, or without, if this is 
not the case, we will generally be obliged to resort to local remedies. 
And first of all is cleanliness. The parts, externally and internally, 
must be subjected to thorough and frequently repeated ablutions. 
The syringe may and should be brought into use for this purpose 
from three to a dozen times a day. The water used for ablutions may 
be impregnated with sal soda very appropriately, or some fine toilet 
soap. I have found much advantage, when there was no eruptive 
accompaniment, from two drachms of the tincture of the chloride of 
iron in a quart of water, three or four times a day. This is especially 
useful when there is leucorrhcea, and a congested, dark appearance of 
the mucous membrane. When there is a vesicular eruption, the 
recommendation of Dr. Dewees, to sprinkle the parts with powdered 
borax, and keep them exposed as much as possible to the air, will be 
of great service. Professor Simpson uses chloroform, in the forms of 
vapor, liniment, or ointment, with good effect. The infusion of tobacco, 
applied freely, two or three times a day, is recommended by the same 
author. Simple cerate, or oxide of zinc ointment containing 5 to 10 
per cent, of carbolic acid is a good palliative. When the mucous 
membrane is much inflamed, a solution of hydrocyanic acid, ten drops 
to the ounce of water, often gives great relief. A strong solution of 
tannin and aqueous extract of opium is also applicable to this class of 
cases. An excellent palliative is pure glycerin. It may be introduced 
into the vagina by saturating a plug of cotton, passing it up through a 
glass speculum and allowing it to remain there for ten or twelve hours. 
We should take the precaution to attach a thread or cord to the cotton 
so that it may be readily removed. One of them introduced every 
twelve or twenty-four hours is often enough. We should also apply 
it between the labia in the same way. As explained by Dr. Sims, who 
first recommended its use, the glycerin induces copious serous deple- 
tion from the congested mucous membrane, thus relieving it. 

In cases of some duration I have often been enabled to produce a 



CORRODINGr ULCER. 155 

decidedly favorable change by applying the tincture of the chloride of 
iron in full strength with a brush once a day to all the mucous mem- 
brane of the vulva, and as far in the ostium vagina? as I could pass 
the hair-pencil. The first burning sensation is succeeded by great 
amelioration of the sufferings, and finally, in many cases, by a cure. 
When this fails, we may sometimes succeed by making a similar 
application of a solution of nitrate of silver in the strength of 3ss to Ij 
of water. This last application should not be used oftener than once 
in two days. In the use of all these remedies we must not lose sight 
of the ablutions, nor fail to search for particular local causes, and try 
to remove them. As has been very judiciously remarked by Professor 
Simpson, we will find great advantage in alternating the use of appro- 
priate remedies, instead of using the same kind all the time. The 
obstinacy of this affection will require great patience in many instances, 
as well as ingenuity in using remedies. 

Corroding Ulcer. 

I have met with a number of cases of corroding ulcer of the vulva 
in children, which have been the cause of great suffering and appre- 
hension. It occurs most frequently in children, but is occasionally 
met with in adults. There is in each case usually but one ulcer, and 
it is most commonly situated on the lesser labia at first, and spreads 
to surrounding parts. The ulcer is ragged and irregular, not much 
excavated, with a dark foul-smelling covering, and the discharge from 
it is sanious, fetid, and excoriating. It is not generally rapid in its 
progress, and sometimes lasts for months, creeping from one part to 
another until the anatomical features of the vulva are almost entirely 
effaced. I have not met with this form of disease except in very 
debilitated, sallow, and badly nourished persons. The state of the 
system leading to this sort of ulceration I have thought to be more 
particularly the result of living in poorly ventilated houses, but coupled 
also with imperfect nourishment, or with nourishment of an improper 
character. 

It is generally obstinate, and yields but slowly to judicious treat- 
ment. 

We should endeavor, as one of the main objects, to correct the con- 
stitutional condition as speedily as possible. To this end the circum- 
stances of the patient should be changed to the most favorable sort. 
Good ventilation at home, frequent and prolonged exposure to the 
fresh air, nourishing diet, of which animal food should be a large 
ingredient, and comfortable clothing, with thorough cleanliness, are 
indispensable to success. The bowels should be kept in as correct a 
condition as possible by gentle laxatives. The digestion, which is 
always feeble, if not otherwise faulty, may be improved by the admin- 



156 DISEASES OF THE VULVA. 

istration of infusion of cinchona, quassia, or colomba, with the mineral 
acids, the sulphuric being perhaps the best. The chlorinated tincture 
of iron is also an excellent general remedy. The next thing to be 
accomplished is to convert the ataxic, half-sloughing, and corroding 
chronic ulcer into an acute inflammatory one. This is done by pro- 
foundly stimulating it with the stronger caustics. The one which has 
seemed to me to be most successful is the caustic potassa. It should 
be applied to the whole surface by passing a stick, not very rapidly, 
all over it. After this burning we may dress the ulcer with calamine 
ointment twice a day. This will almost immediately improve the 
condition of the sore. Unless there is some considerable firmness 
around and beneath it, caused by the effusion of fibrin in the submu- 
cous substance in thirty-six or forty-eight hours after the application 
of the caustic potassa, not much good will result from it, and it will be 
necessary to resort to it or some other in a few days. The strong- 
nitric acid is also very useful. I have not tried the actual cautery, 
but should expect it to be very useful. We may often cure this ulcer 
by the weekly application of the solid nitrate of silver, dressing it 
between times with lint saturated with black wash, calamine ointment, 
or with iodoform gauze. We ought not to be afraid of strong treat- 
ment, nor to continue it in conjunction with a highly roborant general 
course of exercise and diet. 

Gangrenous Vulvitis, or Noma. 

This is a very severe and generally fatal affection of the genital 
organs, occurring usually, if not wholly, among children. It may 
attack one or both sides simultaneously. In the few cases I have 
seen there appeared a bleb or blister on the inside of the mucous sur- 
face of the labium, which at the same time became enlarged, hard, 
tender, and painful. In a few hours the blister breaks, and from its 
side a not very abundant but acrid serum is discharged. At this 
time a peculiar odor is emitted from the parts. All around the ash- 
colored surface, which represents the place where the blister was de- 
veloped, the substance of the labium is very hard and much swollen. 
In two or four clays the affected side is in a state of gangrene, the 
discharge is very much increased, the parts upon which it runs are 
excoriated and inflamed, and an intolerable stench is exhaled. I 
have not seen an instance in which the gangrenous parts were cast 
off, the patients having died beforehand. Generally, though not 
always, in the very beginning, the circulation and nervous system 
are very much disturbed. The pulse is quick and feeble, the patient 
nervously restless, or else stupid, the extremities cool, the body- 
particularly about the pelvis— hot, the tongue furred, generally brown, 
and the skin dingy and sallow. As the disease advances the pulse 



URETHRAL EXCRESCENCES. 157 

becomes still more rapid and weak, the extremities cold, the mind 
wandering, and the restlessness amounts to the frantic efforts of some 
sort of delusion. The tongue becomes dark brown or black, the teeth 
are covered with sordes, and in the end the patient often sinks into 
profound coma, and dies. 

The disease runs its course sometimes in forty-eight hours, and 
again, in milder forms, it may last five or six days. The causes, 
although unknown, must undoubtedly be of a depressing nature, 
overwhelming the organism very rapidly. It occurs sporadically, 
when it is comparatively mild, and epidemically when severe. In 
this last state it is very rapidly fatal. 

The prognosis is very bad, as it is always, or pretty nearly always, 
fatal. The profession, so far as I am aware, has not decided whether 
the disease is a general one, and the affection of the genital organs an 
incident, or whether the local disease inaugurates the general symp- 
toms. The former is most likely the truthful interpretation of the 
phenomena. 

In such a disease there is little prospect of a cure by treatment ; we 
should, nevertheless, institute a course clearly indicated by the symp- 
toms and signs. The general treatment should be strongly stimulant, 
tonic, and supporting ; quinia, brandy, tincture of cantharides, and 
beef essence, as much as the patient can bear, should be administered. 
I do not think the strong caustic local treatment, generally advised, 
any better, if as good, as the charcoal and yeast poultices, chloride of 
lime, anodyne fomentations, and cleanliness. Much attention should 
be devoted to thorough ventilation, isolation of the patient, and the 
neutralization of the fetor by disinfectants. 

Urethral Excrescences. 

Caruncles of the urethra; vascular tumor at the orifice of the 
urethra : These names have been given to small tumors springing 
from the mucous membrane of the vulva, immediately around the 
urethral orifice, or from the lining of the urethra itself. They are 
generally solitary, but sometimes there are several. Sometimes they 
are sessile, and seem to be a hypertrophied fold of the mucous mem- 
brane of the orifice ; at others they are polypoid in their attachment. 
In size they vary from a pin's head to a small nut. They also vary 
in their appearance. As before remarked, they sometimes resemble 
in color, consistence, and polish the mucous membrane upon which 
they are planted ; while in other cases they are quite red, almost 
scarlet, very soft, and easily broken. They differ in their anatomical 
properties quite as much as in appearance, seeming in some instances 
to have no more vessels and nerves than other portions of the neigh- 
boring tissue, while in others they are formed mostly of capillary 



158 DISEASES OF THE VULVA. 

bloodvessels and loops of nerves. They are a morbid development 
of existing tissues instead of a growth of abnormal substance. These 
tumors are often observed, particularly the more dense and light- 
colored varieties, without giving origin to any symptom that would 
lead to their detection ; on the other hand, in many instances, they 
often produce the most excruciating suffering. The kind of caruncle 
that has seemed to me to be the important one is the blood-red tumor 
projecting from the mouth of the urethra and attached by a small 
neck. A few weeks since I met with one of these of crescentic shape, 
attached by a neck that arose from the concave margin, and had its 
other attachment inside the urethral orifice. It would not have 
weighed two grains, but it caused agonizing symptoms. It must not 
be supposed that all of the varieties will not occasionally cause great 
pain. The symptoms of their presence are almost always connected 
with the evacuation of the bladder and attempts to handle the part. 
The passage of urine causes the most excruciating suffering from pain 
and tenesmus, the patient often straining for several minutes after the 
complete discharge of the urine. The slightest touch, also, is the 
cause of great pain. The diagnosis cannot be clear without an ocular 
examination. If the parts are exposed to a good strong light, and 
the labia separated, the excrescence will be at once discovered, unless 
it be quite inside the urethra. If any doubt exists, we should intro- 
duce the finger into the vagina, and press the urethra forward. It is 
difficult to say, with truthfulness, what are the causes of these carun- 
culse. My cases have been in patients obviously deficient in cleanli- 
ness. This seems to have been the cause in that which came under 
Dr. West's observation. 

The treatment is simple, and consists in two main objects : 1st, the 
thorough removal of them ; and 2d, the production of a profound 
impression upon the point of origin. In fact, the tissues from which 
they spring should be destroyed to a slight depth. The first object 
may be most readily gained by snipping off deeply with scissors ; and 
the second by holding nitric acid, or applying the actual cautery, to 
the place until the nidus is destroyed. 

Vascular Urethra. 

Analogous to the caruncle is the vascular urethra. It gives rise to 
the same train of symptoms, though not so intensely distressing, and 
is very persistent. It occurs more frequently in patients near the 
climacteric period, although I have seen it in much younger persons. 
When the labia are separated, and the parts exposed to a good light, 
the urethra is seen to be patent, and the tissues around the orifice 
swollen and of deeper hue than usual. The mucous membrane of the 
urethra is of an intensely scarlet color, and, upon minute inspection, 



HYPERTROPHY OP THE CLITORIS AND NYMPHA. 159 

the vessels may be seen enlarged ; it is very tender and sensitive to 
the touch, slight contact producing exquisite pain. There is great 
burning and sense of cutting when urine is voided, and all the symp- 
toms, even the sympathetic nervous derangements, attendant upon 
caruncle. This condition is not incipient caruncle, for there is no 
elevation, no protrusion, and the condition lasts for years without 
material change of substance. The treatment I have found most 
effective is dilatation and the use of strong nitric acid, applied cau- 
tiously to the membrane inside the urethra. The passage of a large 
urethral sound twice a week sometimes exerts a beneficial alterative 
influence. 

Hypertrophy of the Clitoris and Nympha. 

It is very rare that we meet with hypertrophy of these organs 
without morbid change in the tissues. There is either cystic devel- 
opment in their substance or degeneration of the membranous tissues. 
The two diseases that seem to contribute most frequently to this en- 
largement are syphilis and elephantiasis. 

Treatment. 
Removal by the thermocautery. 



CHAPTER VII. 

LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

The structure of the perineum and pelvic floor, and their relation 
to each other and to the uterus, have been briefly considered in the 
first and third chapters. A few preliminary observations about their 
relation to labor will also be necessary to prepare the way for a dis- 
cussion of the treatment of injuries of these parts. 

Preliminary Observations upon the Conditions leading to Injuries of 
the Parturient Canal. 

At the beginning of normal labor the occiput projects into the pelvic 
cavity below the level of the pubic arch. As the external os uteri di- 
lates and is drawn up over the head, elevating with it the pubo-uterine, 
sacro-uterine and broad ligaments, the bag of waters presses down 
against the pelvic floor, dilates the vagina, fills the pelvis, and in some 
cases protrudes at the vulval orifice. The fetal head, following the 
bag, dilates the more rigid parts, and is directed by the conformation 
of the pelvic cavity over the folded and retracted perineal raphe into 
the dilating vaginal and vulval orifices. 

One of the most frequent deviations from this method is a prema- 
ture rupture of the membranes. In a much larger percentage than 
has been supposed they rupture at or before the beginning of labor* 
and allow the amniotic fluid to drain off. As soon as it has escaped 
active labor pains come on, drawing the cervix rapidly over the head, 
and often producing a laceration of the cervix that may extend into 
the vagina, and thus inaugurate a series of lesions. Having neither 
its normal protection, the pouch of membranes, nor an oozing amniotic 
fluid to lubricate it, the vagina is dragged down toward the vulva, and, 
if the upper part be thus lacerated or the head be proportionately too 
large, may be torn loose from the receding uterine ligaments and their 
surrounding connective tissue. As the head descends the mucous mem- 
brane may be loosened from its intimate fascial connection with the 
levator vaginae and pubic arch, and perhaps torn asunder along with 
the weaker perineal tissues. The rectum may also be dragged loose 



* According to G. W. H. Kemper (Am. Jonrn. Med. Science, April, 1885, p. 412) 
and J. C. Bliss they occur in from seven to ten per cent, before the onset of labor. In 
my private obstetrical practice, which is mostly among delicate or sickly primipara, 
and multipara who have uterine disease, the percentage of such premature ruptures 
has been during the past year as high as forty per cent. 



THE SCIATIC AND COCCYGEAL SURFACE. 161 

from its naturally firm and unyielding sacral attachments, behind and 
below the sacrouterine ligaments. If the membranes rupture later, at 
any time before reaching the vulva, a similar unfavorable change occurs 
in labor, but it involves chiefly the parts lower down. Other things 
being equal, the greater the amount of perineal dilatation at the time 
of the rupture of the membranes, the more will any injuries that may 
occur be confined to the lower and superficial structures. 

When the head remains at the pelvic brim during the first stage of 
labor, the upward traction upon the cervix, vaginal fornices, and con- 
tiguous structures separates and attenuates them, and deprives both 
the cervix and vagina of their connective-tissue support. This length- 
ening of the parturient tube from the internal os down diminishes also 
its transverse distensibility and predisposes to laceration. 

Expulsive efforts during the first stage are very commonly employed 
by multipara, and occasionally b} r misdirected primipara. This forces 
the foetus down before the maternal parts have had time to retract, and 
unduly hastens dilatation while interfering with retraction. 

A rapid instrumental delivery, by affording too little time for 
moulding of the head and the dilatation and adjustment of the ma- 
ternal tissues, must lead to a laceration in all but the previously 
lacerated or abnormally relaxed outlet. The greater number of forceps 
are so constructed that one or both blades press or cut into the vaginal 
levator vaginae and constrictor cunni of one or both sides and, by the 
irritation they produce, tend to bring on disastrous expulsive efforts. 

Imperfect development of the pelvis, vagina and perineum, pelvic 
deformity, cicatrices, rigidity from age, fetal abnormalities, etc., consti- 
tute conditions that must also be understood by the gynecologist, and 
which should be carefully studied in treatises on obstetrics. 

The Mechanism of Laceration and Injuries of the Perineum and 
Pelvic Floor. 

Whether it be admitted or not that the bag of waters can as a rule 
be preserved to dilate the vaginal and vulval outlets* a reference to 
Figs. Ill and 112 will show the advantage the perineum gained by 
such preservation. 

The Sciatic and Coccygeal Surface. 

The curved lines (Fig. Ill), marked to represent the anterior edges 
of the smaller sacro-sciatic ligament and coccygeus muscle, run from 

* In nine-tenths of my private obstetric cases during the past year in which the 
membranes remained intact until complete dilatation of the external os uteri, they 
protruded from the vulva before rupturing. In one-third of these cases the head was 
born with the membranes intact. 

11 



162 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



the ischial spines to the coccyx. They may be felt, at the beginning 
or subsidence of a pain, as the anterior edge of the flat surfaces upon 
which the frontal region rests while the perineum is being dilated. 
It will be noticed that the vulval orifice is larger in Fig. Ill than in 
Fig. 112. while the frontal region is still completely supported upon 

Fig. ill. 




Folding of the Perineal Body in Normal Labor when Dilated by means of the Bag of Waters or 

Caput Succedaneum (%). 
The dots on the perineal body indicate connective tissue containing fat. 
p. ft, post, commissure ; e. c. c, edge constrictor cunni or vulval sphincter ; e. I. v., edge levator 
vaginfe or vaginal sphincter; a., anus ; e.l.a., edge levator ani; e.l.c, edge levator coccygei ; 
e. ft, edge coccygeus ; s. .?. I, smaller sacro-sciatic ligament. 

these planes. This part of the pelvic floor is dilated but little, and is 
seldom injured except by contusion. Schatz diagnosticated one lacera- 
tion extending by the side of the coccyx * 

Plane of Obturato- Coccygeus. 
From this plane to the curve marked in the figure as the edge of the 
levator coccygei, and which can often be traced as a ring around the 
head extending from the pubic bone on either side to the tip of the 

* Archi-v fur Gynecologie, vol. xxii., p. 302. 






THE LEVATOR COCCYGET. 



1G3 



coccyx, lies the posterior section of the levator ani, or obturato- 
coccygeus. It is less rigid, and has only fascial attachment laterally 
Direct lacerations here are seldom observed, except after forceps de 
liveries, as but a moderate dilatation is required. 



A loosening of the 



Fig. 112. 




Flattening of the Perineal Body in Labor due to rigidity of the outlet or improperly directed 

force {%). 

p. c, post, commissure ; e. c. c, edge constrictor cunni; e. I. v., edge levator vaginae (hymen) ; 
a., anus ; e. 1. a., edge levator ani ; e. 1. c, edge levator coccygei ; e. c, edge coccygeus ; e. s. s. I., edge 
smaller sacro-sciatic ligament. 

reflected obturator fascia about the white line, sometimes occurs on 
one side. Contusion from the blade of the forceps, or a diffuse uni- 
lateral laceration of fibres are the usual forms. 

The Levator Coccygei. 
The levator coccygei fibres may be lacerated by forceps blades, by 
extension backward from the levator ani, or by a general overdistension 
from a large head, abnormal mechanism, malposition, etc. A slight 
laceration is often sufficient to relax the anterior edge and save the 
posterior fibres unless the forceps blades project, or labor be completed 
too rapidly. 



164 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

Tli e Plane of the Levator Ani Proper. 

From the coccyx forward to the anus extends the true levator ani. 
Its anterior edge can generally be felt during labor by a little manipu- 
lation and careful palpation a little lower than that of the levator 
coccygei. and going to the sphincter ani. This portion is but seldom 
deeply lacerated, for it is not only powerful enough to resist a too rapid 
dilatation, but its dilatation commences early or before the head gets 
far enough down to be delivered suddenly. And as it is dilated during 
rotation of the head, it is usually lacerated laterally instead of at its 
median attachment — either by the occiput upon one side or the parietal 
protuberance on the other. The tear usually commences at or in front 
of the ring and extends backwards beside the rectum, and occasionally 
into it. In fact the majority commence in the levator vaginae and will 
be considered in connection with lacerations of that muscle. 

Plane of the Levator Vagina? or Vaginal Sphincter. 

The ring corresponding to the inferior edge of the levator vaginae or 
vaginal sphincter is the most easily felt of any, after the fetal parts 
have begun to dilate it, and may be felt to reach from the posterior 
surface of the pubic bone a little at one side of the median line, around 
the occiput in an almost complete circle to the other side. 

Being the shortest muscle that completely surrounds the emerging 
head, and at the same time so intimately connected with, and supported 
by, the perineal septum and deeper pelvic fascia, the levator vaginae is 
frequently the starting-point of deep and complicated lacerations. On 
account of the lateral position of the occiput the greatest strain is 
brought to bear upon it, as upon the levator ani at the sides. If, then, 
a laceration occurs before the head has rotated to a median position, it 
will be at one side ; if it be delayed until after that time, the strain 
will be equalized and the tear will occur along the median line raphe. 
If the levator vagina? resists rupture and yet remains but little dilated, 
until the occiput has rotated to the centre, a diastasis of the different 
muscles antero-posteriorly is apt to occur. Fig. 112 represents about 
the limit of the separation of the rings representing the anterior 
edges of the muscles before they must be torn apart. Thus we may 
have a transverse laceration or antero-posterior diastasis of the levator 
vaginae either from the levator ani behind, or from the perineal septum 
and constrictor cunni in front. It follows, of course, that if the rings 
of the levator ani and levator vaginae be sufficiently dilated before the 
larger presenting diameters engage in them, as in Fig. Ill, these trans- 
verse lacerations will never occur, and the lateral ones very seldom. 
As the lacerations at one side of the median line through the levator 
vaginae always swerve toward the median line, I shall call them diago- 
nal lacerations. 



PLANE OF THE LEVATOR VAGINAE OR VAGINAL SPHINCTER. 165 

The diagonal lacerations, if they occur before an ample dilatation 
of the levator ani, may extend back into that muscle, beside or into 
the rectum, or forward into the fourchette. It is quite common for 
the levator vaginas and levator ani to become bruised and weakened, 
but to remain intact until the head has rotated pretty well to a median 
position, and then to split back diagonally on both sides, somewhat 
farther and deeper on one side than the other. A V is thus formed 
which is usually converted into a Y by an extension along the median 
line through the median line raphe. Sometimes one side of the Y is 
so short as to be scarcely noticeable, and we have an imperfect f. 

When a diagonal laceration of one side extends into the perineal 
body it may, if the extension be gradual, assume the character of a 
flap laceration, and present a sort of S-shape when drawn together. 




T,r anus 

Diagonal Flap Laceration, left side (unilateral), drawn together, 
c, fourchette ; b, position of rupture into levator vaginae ; d, lower end of laceration externally 
in the skin ; a, vaginal extremity of laceration ; abed, line of superficial laceration ; aid, bottom 
of laceration under the flap. The flap may he raised beyond this line. When the parts are not 
drawn together the interrupted line aid is usually drawn toward the sound side beyond the 
median line. 

It occurs in about the following manner : The head produces a super- 
ficial diagonal laceration and then, in rotating, strips up the mucous 
membrane and the contiguous fibrous tissue to or beyond the median 
line, at the same time that it deepens the lesion diagonally backward. 
After having come to press more centrally the head ruptures the con- 
strictor cunni a little nearer the median line, and then having rotated 
to the middle extends the laceration either directly into the raphe, or 
through the transversus perinei into it, and out through the external 
skin. 

Thus a large flap is raised and an oblique as well as diagonal lacera- 
tion is produced. Fig. 113 represents the laceration when the parts 
are brought together after labor. Abe is the rent along the vulvo- 
vaginal surface, and represents the portion which was within the 
vulval orifice and in contact with the head. C d is the cutaneous 



166 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

surface, b is the point on the ring of the levator ani, and c the point 
on the ring of the constrictor cunni. The interrupted line indicates the 
bottom of the tear. Thus the upper end is through the levator vaginas 
and sometimes the levator ani, the middle portion slants through the 
constrictor cunni and sometimes the transversus perinei to the raphe, 
while the external end is partly in the median line. As the tear com- 
mences before much dilatation of the lower end of the parturient canal, 
it is apt to be deep and destructive, and yet to present quite an inno- 
cent appearance, for the flap drops into the wound and partly covers 
it up. 

Schatz has described a laceration of the levator vagina? et ani at 
their bony pubic attachments.* I have often noticed the falling away 
of the tissues at the pubic attachment, alluded to by him, but have 
almost invariably found the condition due to extreme relaxation or to 
a laceration at some distance from the bone. This falling away of 
tissue at one side is quite common, laceration at the bony attach- 
ment exceedingly rare. The transverse lacerations behind the levator 
vaginae are usually submucous, and are more of the character of an 
attenuation of the submucous tissues ; those in front of the muscle are 
apt to be accompanied by one or more of the other varieties. For 
instance, as the constrictor cunni and levator vaginae are separated by 
the transverse rupture of the raphe, the head, suddenly relieved of a 
part of the resistance, produces a slight backward diagonal laceration 
at one side, or both, and then, in passing the vulva, produces a median 
laceration forward. If such a laceration is drawn together a peculiar 

figure is produced . . If the levator ani give way in the median 

line, as is apt to be the case after the head has got so far down, the re- 
sulting figure would be an inverted T J_ , which by extension may be 
converted into a cross -K Or, if the median laceration of the levator 
vaginae be fan-shaped, we have a fan upon a transverse line ^ . By an 

extension into the vulva the fan may get a handle - y . The V- or Y- 
shapes may also occur with the transverse and give rise to correspond- 
ing figures -^~ - V -. ^ the transverse rent be unilateral, half of these 

figures may be produced with half of the transverse line wanting Y-. 

When a V-shaped laceration occurs before the transverse, the trans- 
verse laceration through the raphe may be merely represented on the 
surface by a deepening and widening of the V, especially about its 
angle. A transverse laceration accompanied by a short diagonal lacera- 

* Op. cit. 



THE VULVAL PLANE OR RING. 167 

tion backward at either end may assume the shape of a crescent or 
bow. 

When the head rotates to the median line before lacerating the 
levator vaginae, we may get a superficial laceration in or about the 
median line either single or fan-shaped, with or without an extension 
through the vulva. These are apt to commence at the constrictor 
cunni and extend backward and forward. 

Plane of the Constrictor Cunni or Vulval Sphincter. 

The constrictor cunni or vulval sphincter is not only longer than 
the levator vaginae, but is less intimately connected with the deeper 
muscles and fascia, and, therefore, is normally more easily dilated and 
less frequently ruptured. The ring marking the anterior edge of the 
constrictor cunni is readily felt by depressing the softer tissues of the 
labia and posterior commissure at the vulval outlet, as the head re- 
cedes after a pain. It extends from the anterior surface of the sym- 
physis, near the superior junction of the labia minora, to the four- 
chette. When the vaginal and vulval orifices are dilated gradually by 
a proper wedge, the fascial union at the raphe is maintained, the vul- 
val muscle expands with the vaginal, and is safe as long as the latter 
maintains its integrity. But when there is no dilating wedge, and the 
muscles are stretched and flattened over the presenting part, as in Fig. 
112, the vulval and vaginal rings become separated, and the raphe is 
over-stretched antero-posteriorly, or even torn across, The ring at the 
constrictor cunni is left undilated, and when the levator vaginae gives 
way or becomes sufficiently dilated, may be obliged to stretch so 
rapidly before the released head that it must part asunder. Such is 
usually the case in primary lacerations of these superficial parts. 

The great majority of deep lacerations into the constrictor cunni are 
secondary to lacerations of the vaginal entrance. When they occur 
primarily, or without any foregoing lesions, they are commonly 
median lacerations, for they are produced after the head has rotated 
to a central position, and it is after the pressure has become equalized 
that the strain upon the perineal tissues centres in the raphe. Lacera- 
tions commencing in the levator vaginae also tend to be completed 
externally through the median line. Primary lacerations commenc- 
ing in the median line at the constrictor cunni may extend straight 
back into the levator vaginae, but usually very superficially. Trans- 
verse lacerations external to the constrictor cunni occasionally occur, 
but are of little practical importance. 

The Vulval Plane or Ring. 

Even when the parts are normally relaxed and dilated, the vulval ring 
through the labia and posterior commissure is not sufficiently dilated 



168 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

for the head to pass quickly, and unless the expulsive efforts are mo- 
derated or the head held back, must usually rupture transversely or 
in the median line. If the external parts be rigid, the condition rep- 
resented in Fig. 112 results. Thus quite an extensive superficial rup- 
ture of the vulval and external cutaneous surfaces may occur without 
invading anything else but fatty connective tissue. But as the skin is 
the most extensive and extensible of all perineal tissues, it would, if 
given time, seldom lacerate at all. 

Lacerations Extending into the Transversus Perinei and Sphincter Ani. 

Unilateral diagonal lacerations extending out through the vulva 
may extend through the transversus perinei at the side of the raphe 
and even through the sphincter ani. The double diagonal may also 
extend along the raphe down to or through the sphincter, without 
necessarily involving the lining membrane of the anus. The earlier 
the deeper lacerations commence, and the more rapid the delivery, the 
greater the liability to such extension. 

Lacerations of the Perineal Septum. 

The perineal septum is nearly always slightly ruptured in several 
places with the hymen which fringes its perforated edges. An early 
deep diagonal laceration may extend forward from the levator vaginae 
through the hymen and septum, and so relax the perineum as to pre- 
vent farther injury. A laceration through the transversus perinei at 
one side of the median line usually goes through the lower border of 
the septum also (see Fig. 22) and thus practically divides it in twain. 
Such an accident must of course completely relax the whole fascial 
circumference of the vaginal orifice and leave the lower end of the 
urethra unsupported. In conjunction with a laceration through the 
levator vagina? it leaves almost the whole urethra and periurethral 
connective tissue unsupported and sagging down into the vulva. 

Lacerations of the Deep Pelvic Fascia. 

The deep fascia is reflected over all the muscles, and is lacerated 
with them, and only without them when the laceration takes the 
direction of the muscular fibres. Hence the mechanism of the lacera- 
tions of the muscles will suffice for the fascia also. 

The Flap Lacerations. 

One of the most complicated of the flap lacerations, the unilateral 
or S-shaped, has been described among the diagonal ; yet almost any 
laceration, except the median, is liable to be complicated by the rais- 
ing and displacement of a flap of mucous membrane or skin. Such 
barking of the tissues occurs during the movement of the head over a 



CENTRAL RUPTURES — IRREGULAR LACERATIONS. 169 

superficial laceration that is slow to extend into the deeper tissues, 
and particularly so if the line of the tear makes a curve or an angle. 
The tongue of vaginal tissue in the V-shaped laceration is sometimes 
stripped back enough to allow of considerable retraction. The pro- 
jecting parts in angular tears, or tears crossing one another, as when 
a transverse laceration is compounded by an antero-posterior, may be 
stripped back by the head if it advances before extending the lacera- 
tion deeper. 

The deep or essential part of the tear does not always correspond 
with the superficial lesion, and the displaced flap may be retracted 
from where it belongs and grow over and into the lacerated surface, 
and thus converts deep structures into submucous tissue. They 
show how mistakes may be made in depending entirely upon the 
cicatrices for the diagnosis of lacerations. 

Central Ruptures. 

Ruptures through the perineal centre, leaving an untorn bridge of 
tissue about the fourchette or posterior commissure, are usually a 
combination of lacerations, extending in various directions. They 
occur when the vulval rings are rigid, and hold up the fourchette 
while the head is driven rapidly against the perineal centre. When 
the advance of the head is arrested before being driven through the 
perineal centre, it may be made to pass through the vulva over the 
untorn bridge of tissue. This is especially the case if the central 
rupture be produced by a projecting foot, knee, or elbow, that can be 
pushed up out of the way. 

According to Charpentier * who collected the reports of fifty-six 
cases, the factors in their production are : 

1. Exaggerated height of the symphysis pubis. 

2. Condition of the perineum, viz., smallness and rigidity. 

3. Irregularity and exaggerated intensity of the pains. 

Irregular Lacerations. 

When the vulval and vaginal rings remain long undilated, so that 
the perineum becomes stretched over the head like a membrane, the 
maternal structures involved may finally lose all of their normal 
characteristics, and burst in a stellate or otherwise irregular manner, 

producing, when drawn together, all sorts of figures, -44- \-V. ./ -J. 

Such forms are generally accompanied by considerable bruising of the 
parts, and show but little tendency to primary union of surfaces, but 
on the other hand are apt to cicatrize extensively, and leave a very 
firm, although small and mutilated, perineal body. 

* Archives de Tocologie, November and December, 1885. 



170 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

Concealed Lacerations. 

Lacerations of the deeper structures, that do not involve the skin 
or mucous membrane, are almost invariably of the transverse variety, 
or are made up of a number of minute lacerations in the muscular 
fibres and fasciae over a limited (but not linear) area, or over a half 
or the whole of the perineum or pelvic floor. This latter is the diffuse 
variety due to over-distension, and may thus be regional or general. 

The reason why the diagonal or transverse lacerations scarcely ever 
occur, without involving the mucous membrane or skin, is because 
internally the levator vaginae is so intimately connected with the 
vaginal wall, that they must tear together ; and externally the parts 
become so flattened and pressed together before laceration primarily 
occurs, that the vulval skin, if not the external, must rupture with 
the raphe. I have sought scores of times for a submucous or subcu- 
taneous parting, or diastasis, of the muscles and fascia in the median 
line raphe, but ' have never yet failed to find evidence, either of a 
co-existing superficial laceration, or else of the unbroken attachment 
of the muscles to the median line. When, however, a laceration re- 
mains uncicatrized, the new skin or mucous membrane is apt to make 
it appear subcutaneous or supravaginal. Diffuse laceration and re- 
laxation also, in consequence of the falling away at the sides, gives a 
deceptive appearance of diastasis along the median line. An unusual 
mobility and flabbiness of the rectum is also apt to give the inexpe- 
rienced a notion of the parting of muscles. 

But strangely enough the condition that is usually mistaken for 
such a laceration is one which extends transversely through the raphe 
between the levator vaginae and constrictor cunni, and leads to a 
diastasis of these muscles for each other along the transverse tear. 
The levator vaginae is thus separated from the lower perineal tissues, 
relaxing the vulval and rectal sides of the perineal body, and leaving 
the cutaneous side to sustain the full force of the abdominal pressure. 
As a consequence the constrictor cunni relaxes until it lies against 
the pubic ramus like a retracted curtain, and allows the loosened rec- 
tum, covered by the attenuated vaginal wall, to bulge over the sagging 
fourchette. The levator vaginae is drawn up but not lacerated. 

More or less diffuse laceration probably occurs in the great majority 
of first labors. In the levator ani it may occur along the course of 
the occiput in occipito-posterior deliveries or of the forehead in nor- 
mal presentations of a large head. It may involve any one of the 
planes of the perineum or pelvic floor of one or both sides, or even 
the whole perineum and pelvic floor, as during capping of the head. 
The muscular fibres lacerate separately and irregularly throughout 
the given area like the rubber threads in a worn-out elastic suspender, 
The skin or mucous membrane is seldom lacerated to any extent in 
any one place, although it may present slight abrasions or lesions. 



IMMEDIATE EFFECTS OR THOSE INCIDENT TO PUERPERAL STATE. 171 

Contusions about the Bony Walls. 

Contusions about the bony walls ordinarily involve the mucous 
membrane and vulval skin and their underlying connective tissue. 
They result from pressure of the head during its passage. The mem- 
brane may be stripped from its base in several different places. J. 
Matthews Duncan in one case counted as many as eight separate 
lacerations of the vagina, perineum, and vulva. 

Lacerations Extending into the Rectum. 

A laceration extending into the rectum seldom commences as a 
median one, for, as the head must have rotated under the pubic arch 
before a median laceration can occur (excluding those which are ex- 
tensions of the diagonal or transverse varieties), the rectum will usually 
be pushed back out of the way before the tear begins. Generally a 
single or double diagonal laceration occurs, first involving the levator 
vaginae, and extending into the edge of the levator ani of one side at 
least, and so exposing the rectum. The head, bearing through the 
rent toward the anus, flattens the perineum, including the sphincter 
ani, and, as it rotates to the centre, splits the remaining perineal 
structure through or beside the raphe, down into the rectum and out 
through the anus and skin. A large head delivered rapidly by for- 
ceps is apt to drag down the rectum and lacerate into it. 

Effects of Perineal and Pelvic Floor Lacerations. 

The immediate effects of pelvic floor and perineal laceration vary 
greatly according to the amount of injury done, while the remote 
effects depend less upon the amount of injury than upon the subse- 
quent repair brought about by an immediate union, or by the process 
of cicatrization. 

The Immediate Effects or those Incident to the Puerperal State. 

The immediate effects are a weakening of all pelvic tissues by a des- 
truction of the inferior stay to the pelvic viscera, and thus a removal of 
that support which the inferior portion of the connective-tissue frame- 
work and their inclosed viscera afford by contiguity to those above it. 
In addition to this the direct support which is afforded by the pelvic 
floor to the puerperal uterus, until it becomes small and light enough 
to be held up by the superior or pelvic roof structures, is weakened 
and sometimes partly taken away. 

As a result congestion of the uterus and pelvic viscera, delayed or 
arrested involutions, loss of control over the rectal and vesical dis- 
charges, a general weakening, and an inability to assume with comfort 
the sitting or erect postures within a natural period are frequently 
noticed. When the rectum is opened the subsequent alvine discharges 



172 LACERATION OF THE PERIXEUM AND PELVIC FLOOR. 

are apt to increase and prolong the inflammation and suppuration 
about the lacerated surfaces and so give rise to a state of great suffering. 
I knew one young woman to commit suicide within two weeks after 
confinement to escape her misery. 

Other secondary results, such as septicaemia, inflammation of the 
neighboring connective tissue, etc., belong to such wounds, as to those 
which occur elsewhere. 

Remote Effects. 

Were there no attempts at repair on the part of nature, the remote 
effects of injuries to the parturient canal would be sad indeed. For- 
tunately they are nearly all repaired to a certain extent, so that but a 
small percentage of them, except those which open into the rectum, 
give rise to much trouble afterward. And now that the accoucheur is 
learning how to repair them immediately, the cases left for subsequent 
treatment may be expected in the near future to appreciably diminish. 

Among 150 consecutive gynecological cases among childbearing 
women examined in my office, the perineum was carefully inspected 
in all but seven, viz. : in 143. Evidences of laceration were dis- 
covered in all but eight (135). Of this number all but ten lacerations 
had cicatrized. Of the 125 that had cicatrized only five were operated 
upon, and not more than five others seemed to require it. Of the ten 
uncicatrizecl, five, or all except the very slight ones, required an opera- 
tion. About twenty-five per cent, of the lacerations were slight, in- 
volving only the vulva superficially or the edge of the levator vaginae 
of one side. It was thus determined that, no matter how extensive the 
laceration, if it did not involve the sphincter ani, there was seldom a 
sufficient displacement of parts in those cases in which cicatrization 
had occurred to require an operation, while all lacerations of any 
extent which were not cicatrized required an operation. In two cases 
the external anal sphincter was lacerated, once entirely through to the 
mucous membrane, yet the cicatricial tissue acting in conjunction with 
the internal sphincter and levator ani gave the patients control of their 
evacuations. In but one of this series was the rectum opened. 

Effects upon the Uterus. 

After extensive injury involving the pelvic floor, unless some kind 
of repair occurs, the uterus remains enlarged and congested, the vagina 
voluminous and lax, and the connective tissues soft and but feebly 
elastic, and sometimes infiltrated by deposits. As a consequence the 
uterus sinks low in the pelvis, or is drawn out of position by contract- 
ing deposits in the connective tissue. 

If such contracting deposits be in the upper part of the broad liga- 
ments the fundus will be drawn towards the same side, forward or 
backward according as it extends along the round ligaments or back- 



EFFECT UPON THE BLADDER, URETHRA, AND RECTUM. 173 

wards over the infundibulo-pelvic ligament. If the deposit be about 
the cervix in the sacro-uterine ligaments, the cervix will be drawn rip- 
wards and backwards, and the fundus pressed downwards and forwards 
over the bladder by abdominal pressure (Fig. 53). If the deposit be 
in the vesi co-vaginal septum or anterior layer of the broad ligament, 
the cervix will be drawn forward or to one side, and the fundus in 
some cases pressed by abdominal pressure back against the sacrum. 
The inefficiency of the pelvic floor, or secondary support to the uterus, 
not only throws the weight of the organ but also the entire abdominal 
pressure upon these inflamed and rigid supports. The effect is often 
disastrous, and renewed attacks of inflammation follow every attempt 
at active exercise. 

As the superior uterine supports are only firm enough to hold the 
uterus in position while the involuntary or constant abdominal pres- 
sure is equalized by an efficient perineum and pelvic floor, extensive 
injury of these parts unaccompanied by inflammatory deposits or 
compensating cicatrices will allow the uterus to sink upon the bladder, 
or the cervix to slide downward and forward and stretch the sacro- 
uterine ligaments, until either the os uteri appears at the gaping vulva, 
or the abdominal pressure comes to bear upon the anterior surface of 
the uterus and turns the fundus back against the hollow of the sacrum. 
Sometimes the uterus remains unusually movable and at one examina- 
tion may be found with the fundus against the sacrum, and at another 
with the fundus behind the symphisis pubis. In extreme cases the 
subinvoluted uterus finds its way out into or entirely beyond the 
vulva. 

Effect upon the Bladder, Urethra, and Rectum. 

When the head becomes deeply engaged in the pelvic cavity before 
the external os is sufficiently dilated to allow the structures about the 
pubo-uterine ligaments to be drawn up, the bladder and urethra are 
liable to be caught between the head and the pubes and either dragged 
loose from their attachments, or directly lacerated, or else so contused 
that the tissues will part asunder from the force of mere pressure, or 
in consequence of subsequent necrosis. If now the perineal and pelvic 
floor support to the abdominal pressure be to any considerable extent 
removed, the bladder will be forced by the direct abdominal pressure 
down behind and under the pubic arch and remain there in a state of 
congestion. 

Similarly if the perineal raphe be torn entirely through, the rectum 
may be forced by the reflected abdominal pressure into the vulva. In 
either case the pressure exerted through the prolapsed viscera prevents 
efficient cicatrization, and particularly so if the patient be allowed to 
sit up before the cicatrix can form and contract. 



174 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

Effects upon the Vagina. 

Subinvolution, chronic congestion, plastic enlargement and increased 
weight of the vaginal walls are also the results of the lacerations in 
question. And not onhy does this weighty and redundant tissue find 
its own way out of the vulva, but it drags upon the uterus, bladder 
and rectum, and aids in bringing about that complete series of changes 
in the pelvic viscera whose final sequence is a lodgment of the pelvic 
organs entirely outside of the body. 

Cicatrices in the vagina and supra-vaginal connective tissue may 
not only prevent prolapse of the vaginal walls but may draw T them 
higher up in the pelvis. But as the cicatrix will thus have both the 
weight of the vagina, and perhaps the uterus and abdominal pressure 
to bear, the patient may suffer more than if such cicatricial support 
did not exist. 

Other Effects. 

Thus cicatrices of large size may be sometimes sensitive and trouble- 
some on account of traction and pressure upon them, particularly so 
if previous hyperesthesia or tenderness have existed. Reflex pelvic 
pains and discomfort have been traced to them. Yet when primary 
union does not take place cicatrization is desirable as a healing process, 
and as a prevention of displacement of the structures above it. 

Sterility from a want of retention of the semen, and impotence from 
a want of copulative power, attend only upon the rare and severer 
forms of lacerations. The levator ani is the chief muscle concerned in 
the copulative act, and is scarcely ever sufficiently involved to be thus 
functionless unless the rectum be laid open. Laceration through the 
external sphincter but not through the mucous membrane of the rectum 
is not as serious as would be supposed, since the levator ani and internal 
sphincter ani aided by the cicatrix about the anus often affords satis- 
factory retentive power. Even when the internal sphincter is torn 
through, the levator ani aided by a firm cicatrix may enable the patient 
to control all but liquid or semi-liquid passages. 

Symptoms of Perineal and Pelvic Floor Lacerations. 

The symptoms of immediate lacerations are great soreness of the 
parts to the touch immediately after labor, painful defecation and 
micturition, and, if the rectum has been opened, incontinence of faeces. 
Occasionally hemorrhage may give rise to symptoms of weakness and 
prostration. Later on symptoms of local or general pyemic infection 
may occur as after wounds in general. (See Effects of Perineal and 
Pelvic Floor Lacerations, above.) 

Secondary Symptoms. 

After the wounded surfaces have healed, the most characteristic 
symptoms are those belonging to imperfect involution of the parts, 



VARIETIES OF LACERATION. 



175 



viz., leucorrhoea, constipation or else an inability of the rectum to com- 
pletely expel the fasces, hemorrhoids, weakness or irritability of blad- 
der, feeling of weight about the pelvic outlet, a want of general strength, 
reflex nervous symptoms, etc. Lacerations of the perineum allowing 
of prolapse or inversion of the parts are attended by local irritation, 
ulceration, and the formation of soft projections between the labia ; 
those of the pelvic floor sufficient to take away a part of its support to 
the pelvic connective tissue give rise to such symptoms as are usually 
connected with a sinking of the pelvic organs below their normal 
plane. A strained or sore condition of the superior or pelvic roof 
supports, and a displacement of the pelvic organs are common 
symptoms. 

In making the examination of a patient complaining of symptoms 
which we recognize as due to pelvic diseases, we should by palpation 
and if necessary by inspection always investigate the condition of the 
pelvic floor and perineum as a possible direct or indirect cause of 
some of them. 

Varieties of Laceration. 

A Careful examination of the displacements and cicatrices in the 
series of cases already referred to was made, and the following table 
constructed : 



Median laceration, slight and extensive ( l), • 
Eight diagonal ( \ ), through right levator vaginae, 

Left diagonal ( /), through left levator vaginae, 

Double diagonal or \/ -shaped through both levator vagin 

Double diagonal with forward extension, y -shaped, 

Eight diagonal with forward extension, an incomplete Y ( N J, 

Left diagonal with forward extension, an incomplete Y ( ( \ . 

Diagonal fan-shaped (^^ ), 

Diagonal fan-shaped, with forward extension ( y^ V . 

Left diagonal flap laceration, the S-shape ( \ )> • 

Eight diagonal flap laceration, the S-shape ( / Y . 

Transverse (■ ), 

Transverse with median forward or | -shaped, 
Transverse with median backward or inverted T (_J_), • 
Transverse with median backward and forward, or cross shaped ("T* 
Transverse across double diagonal ( \/ ), .... 



25 

17 

13 

10 

15 
9 
9 



176 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



Transverse across double diagonal with median extension ( V <J, 1 

Median joined to left diagonal ( Y )> ^ 

Median and left diagonal separate ( I )» ^ 

Eight transverse with median forward and backward, crossed by 

right antero-posterior backward ( -4 l ' j, 1 

Transverse joined at right with diagonal ( \_ —> ), .... 1 

Transverse joined at right and left with diagonal, and centrally with 

stellate (\^/), 1 

Median joined to right diagonal and right transverse y -— | ), . . 1 

131 

However cumbersome such a verbose nomenclature of perineal 
lacerations may at first sight appear, a close examination of the figures 
will show how an accurate differentiation cannot be made of such a 
combination of cicatrices without a corresponding combination of 
terms. To students and beginners such a detailed nomenclature must 
be of value as giving a more definite idea of the nature of such lacera- 
tions than b} T merely dividing them into degrees according to their 
extent, but without reference to their character. In ordinary descrip- 
tions they may be designated as the median, the diagonal, the trans- 
verse, the central, and compound — such as the V shaped, Y shaped, 

inverted T ( j_ ), cross ( -f- ), double cross ( TJ" ), L, fan shaped, 

imperfect Y ( ( ) , etc. 

When the tear extends into the rectum the same characters can often 
be discovered and named in connection with a mention of the exten- 
sion into the rectum in order to be properly classified. These are also 
called the complete lacerations, those not opening into the rectum the 
incomplete or partial ones. 

Degrees of Laceration. 

The degree of laceration can best be made intelligible by mention- 
ing the structures involved. 

In median ruptures the cutaneous portion of the raphe may alone 
be lacerated down to the sphincter ani or through it, or into the rec- 
tum ; or only the vulval portion, or fourchette may be involved ; or 
only the vaginal portion (the recto-vaginal septum) may be torn a 
given distance beyond the hymen; or two or all of these portions. 
Again, the skin or mucous membrane may alone be torn, or the raphe 
may be slightly involved, or ruptured through, to or into, the anal and 
rectal mucous membrane, for any given distance. Antero-posterior 



DIAGNOSIS OF PERINEAL AND PELVIC-FLOOR LACERATIONS. 177 

lacerations to one side of the median line may involve the hymen or 
perineal septum, the levator vagina?, the constrictor cunni, transversus 
perinei, the cutaneous surface, rectum, one or all. 

The transverse lacerations may be to the right or left of the median 
line, or entirely across from one pubic fossa to the other. They may 
extend barely through the skin or mucous membrane, or partly or quite 
through the raphe. Or they may be external or internal to the vaginal 
or vulval sphincter, or perineal septum. 

The diagonal lacerations may partly or completely sever one or both 
levatores vagina?, and the hymen or edge of the perineal septum ; or 
the transversus perinei; or may extend into the edge of the levator ani ; 
or may extend to or into the rectum. 



Diagnosis of Perineal and Pelvic-floor Lacerations. 

I. Of the Recent Lacerations. — As after prolonged labor the perineum 
remains relaxed for a short period, a flabby or large vulvo-vaginal 
outlet is of little importance as evidence of laceration, unless the sec- 
ond stage has been short, or unless the enlarged state of the outlet 

Fig. 115. 





ctnus -rftf emits 

Triangular Lacerations (schematic). 
v, vaginal end; I, labia or the sides ; c, cutaneous end. The interrupted line v c represents the 
bottom of the laceration or common base of the triangles. Half of the dotted line 11 represents 
the depth of the laceration or altitude of the triangles. The lines constituting these figures are 
all more or less concave or convex when the surfaces are in apposition, but become straight when 
widely separated by traction. 

continues for several hours. A complaint of great soreness at the re- 
moval of the after-birth, and upon the lightest touch about the pos- 
terior commissure and vaginal entrance is one of the first and most 
reliable signs. A light touch is not painful to the parts after labor 
unless there be a raw surface. If there be no laceration the parts will 
be smooth and either normal in relationship, or evenly flattened about 
the fourchette and posterior commissure. 

Upon inspection through the separated labia and after removal of 
the blood by a soft cloth we can easily detect the triangle formed by a 
median laceration. The yellowish gleam of the subcutaneous fat, and 

12 



178 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

the white fibrous tissue of the raphe are easily recognized, and may be 
easily traced along the median line into the vagina. Sometimes nearly 
all of the laceration will be external to the hymen, or cutaneous ; at 
other times nearly all internal to it, or vaginal. 

The extent of the perineal laceration is not determined by the length 
of the sides of the triangle, but by the altitude or distance from a lower 
caruncle or the lacerated edge of the fourchette to the bottom of the 
rent. Convexity of the bottom denotes shallowness, concavity denotes 
depth, of the tear. Fig. 114 is a long shallow rent convex at the bot- 
tom, Fig. 115 is a short deep one concave or flattened at the bottom. 
When the whole lacerated surface is a uniform expanse of fatty tissue, 
the essential perineal structures are not involved, no matter how long, 
ragged and formidable-looking the edges ; when the bottom of the sur- 
face shows the white torn bands of connective tissue, or the reddish 
ends of muscular fibres, the deeper structures are affected, no matter 
how small the cutaneous or vaginal lesion. When the triangular sur- 
faces are separated at the bottom by an expanse of dark red or dark 
blue membrane, and are made up of the red muscular, white fibrous 
and yellow fatty tissue, the rectum has been opened. The extent of 
the invasion of the rectum may be followed by the edges of the tear. 



IT/ethrcL 



Fig. 116. 

UreXTtrou 





Diagonal Lacerations of the Perineum (unilateral and bilateral), as seen through separated 
labia right after labor. 

As the median laceration seldom extends beyond the external 
sphincter, the red color may be absent from the bottom, but it will be 
replaced by the lighter bluish cutaneous lining of the anus. 

When a transverse, diagonal, V-shaped or irregular laceration occurs 
without an extension into the skin, it may easily be overlooked by the 
inexperienced, since the vulva appears normal from without, and the 
bruised mucous membrane at the vaginal entrance is often about the 
same in color as the raw surfaces. The finger should be introduced 
first to ascertain if sore places be present and to grasp the perineal 
body with the help of the thumb externally. AVhen the finger gets 
into a rent the thumb and finger will notice the absence of the normal 
thickness, and can determine how much of the perineal body is left 



DIAGNOSIS OF PERINEAL AND PELVIC-FLOOR LACERATIONS. 179 

unruptured. Sometimes only the skin will intervene between them. 
When the rupture seems deep the thumb may be introduced into the 
rectum and then approximated to the ringer in the vagina and thus 

Fig. 117. Fig. 118. 



Vagina. VaqiixcL 





LcCbvttfrti 



Shin. 

Fig. 117.— Diagonal Bilateral Laceration with Vulval Extension through Median Line Raphe" 
as expanded for inspection after labor (Y). 

Fig. 118.— Similar Laceration extending into Rectum. (It is difficult to accurately represent a 
laceration into the rectum on a flat surface, as its contour varies with the amount of separation 
of the labia.) 

determine the condition of the raphe, and the amount of tissue left 
over the anus and anterior rectal wall. 

Inspection reveals an oval crescentic or irregular gaping wound, 
whose edges are often ragged and which needs a thorough wiping 
out to be estimated (Fig. 116). 

When a median laceration is united with one or two diagonal ones 
near the fourchette so as to form an incomplete or complete Y, the 
figure when expanded for inspection will present the fusion of the 
double triangle with a half or whole crescent (Fig. 117). When the 

Fig. 119. Fig. 120. 

Ycccjinou VagiTvas 





JjCcbtUTtV 



Fig. 119.— Double Diagonal and Transverse Laceration combined (^/ ), expanded for inspection. 
Fig. 120.— Double Diagonal Laceration with Vulval Extension combined with a Transverse 
one Ovi). 

rectum is invaded there will be a projection of anal skin and mucous 
membrane into the external cutaneous edge (Fig. 118), and a more 
extensive raw surface on either side. 



180 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

The compounding of a V-shaped and transverse laceration looks 
something like the Y-shape, but is much further away from the anus 
(Fig. 119). 

The conjunction of the transverse and Y-shaped makes a star (Fig. 
120). White fibrous and muscular tissue, sometimes the rectal wall 
and, if the rectum be opened, the rectal mucous membrane will be 
seen at the bottom. 

II. Of Old Lacerations. — As the cicatrized edges of lacerated peri- 
neal tissues are not drawn up to their former position, but down into the 
granulating surface, the cicatrix holds them out of place and often 
creates a vulval gap or opening filled with collapsed tissues. The first 
thing then to seek for in diagnosticating old perineal lesions is to 
hunt out by palpation the displaced and relaxed parts. For informa- 
tion upon this point see Chapters I. and III. 

Palpations of Old Perineal Lacerations. 

To determine whether or no the relaxation or displacement be due 
to laceration requires farther attention. When the relaxation is greater 
on one side than the other, or the elevation corresponding to the 
median line raphe (Figs. 67 and 68) is felt drawn to one side, or one 
portion of the perineum, as, for instance, a levator vaginae or con- 
strictor cunni, is flabby and the rest of the perineum firm, the relaxa- 
tion is probably due to a laceration. 

When the median line elevation or raphe is absent, or represented by 
a depression of hardened tissues, and the levator vaginae and constrictor 
cunni, while relaxed and forming a large deep pubic fossa at each side, 
do not form a depression on either side of the median line, there must 
have occurred a median laceration. 

When the tear extends along one side of the median line, the peri- 
neal fossa (See Examination of Perineum, Chapter III.) on that side 
will be the better developed of the two, and will extend down or 
through the transversus perinei. The edge of the laceration and the 
contiguous median line raphe may often be detected by the experi- 
enced finger on the sound side of the median line. Such laceration 
deep enough to involve the transversus perinei, or its central attach- 
ment, leaves a wide depression of hardened tissue in the place of the 
fourchette, which, if the anal sphincter be torn, leads back to the 
membranous edge of the anus. 

A diagonal laceration extending only through one levator vaginae 
gives a deep, but not wide, pubic fossa on the same side. A double 
diagonal, or V-shaped, laceration is accompanied by a deepening of 
both perineal fossae, and sometimes by a raised central tongue or vagi- 
nal mucous membrane which can be felt behind the depressed 
cicatricial tissue situated at or behind the hymen. The Y-shaped lacer- 
ation is known by the same signs in addition to those of a median 



DIAGNOSIS BY RECTAL PALPATION. 181 

laceration, viz., a median line depression and widening and lengthen- 
ing of the pubic fossae. 

A transverse laceration usually produces a transverse depression 
internal to the commissure or fourchette extending into the pubic 
fossa on one or both sides. A wide V-shaped laceration produces a 
similar depression, but it is felt to extend to the bellies of the levatores 
ani around the tongue of mucous membrane instead of into the 
pubic fossae. T-shaped lacerations have a slight transverse depres- 
sion, a widening of the perineal fossa forward, and the longitudinal 
depression instead of elevation of the fourchette or commissure. The 
inverted T (x) has a transverse depression with a normal fourchette, 
but has the perineal fossae deepened and widened backwards only, 
and has a cicatricial line or depression that can sometimes be felt over 
the rectum in the median line, or else allows the ringer to feel the 
folded rectum more easily than natural. 

Stellate, cross-shaped and other compound lacerations may be partly 
diagnosticated by the alterations mentioned above, and partly by the 
large extent of firm cicatricial tissue at their site. 

Occasionally we find a lacerated vulvo-vaginal outlet that is as nar- 
row or narrower, and perhaps firmer at the sides, than normal, so that 
the pubic fossa is as difficult or more difficult to detect as in the virgin, 
yet the fourchette is gone, and its place taken by the sagging urethra 
and vaginal walls. Below the narrow elongated orifice upon the 
shortened but firm perineal body is felt a large firm scar with a nar- 
row extension through the separated carunculse at or a little to one 
side of the median line. This condition is produced by the contrac- 
tion of a large cicatrix drawing the ends of the torn muscles and 
fascia down toward the posterior end of the wound but not toward 
the median line. All of the perineal tissues may be firm, but they do 
not close the vulvo-vaginal outlet. The recto-vaginal promontory may 
also be flattened as far back as the coccyx. 

Diagnosis by Rectal Palpation. 

As the perineal body in section is triangular (Figs. 26 to 31), its size 
and form may be quite accurately estimated (without reference to the 
superficial or visible tear) by a finger in the rectum on its rectal sur- 
face, another on the vulvo-vaginal, and the thumb on the cutaneous 
surface. 

Among the most common losses of substance in the perineum are 
those external to the perineal septum and levator fascia. They are 
due usually to median lacerations which shorten the cutaneous side 
of the triangle and enlarge the vulval angle. This shortening of the 
external cutaneous side and enlarging of the angle goes on progres- 
sively with larger tears, until the sphincter ani occupies the whole 



182 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

cutaneous side, or until the entire body is represented by a flat fascial 
or cicatricial band along the anterior rectal wall, containing portions 
of the perineal septum and levator fascia. Fig. 121 represents by 
lines the parts of the triangle lost by lacerations of different extent. 

Another common form includes primarily the perineal septum and 
recto-vaginal end of the raphe, viz., the diagonal. In the milder grade 
there is merely a shortening of the rectal side depressing the recto- 
vaginal angle, as in the single or double diagonal. In the next grade 
the raphe is destroyed below the constrictor cunni attachment and the 
triangle is cut almost or quite square off as in the deep Y-shaped or 
the T-shaped. When there is but little cicatrization the transversus 
perinei is easily reached on either side by drawing the rectum to first 
one side and then the other so as to render it tense, while the finger 




Fig. 122. 



Fig. 123. 




Fig. 121.— Degrees of Median Laceration through the Perineal Raphe represented by curved 
lines 1, 2. 3, 4. The curves may he increased or diminished at the ends, altering the superficial 
extent without altering the depth or degree. 

Fig. 122.— Degrees of Extension of Diagonal Laceration through Perineal Raphe. The lines 1, 
2, 3, instead of leading from the Raphe into the Rectum, lead to one side of it. 

Fig. 123.— Deformity produced by the Transverse or deep Double Diagonal without forward ex- 
tension. 



presses back along the pubic ramus. The next grade leaves only the 
sphincter ani. In this form we have colpocele,rectocele and cystocele 
unless sufficient cicatrization occurs to act as a substitute for the 
raphe. It is also possible for the lacerations at the upper part to go 
entirely through the raphe, divide the perineal body in two, and de- 
stroy its function without much diminishing its bulk or shape as pal- 
pated or inspected. Fig. 122 represents by lines the portions of the 
perineal triangle destroyed by such lacerations as ascertained by the 
combined rectal palpation. The ease with which the vagina can be 
everted by the finger in the rectum, and the thin membranous nature 
of the tissue over the rectal finger are also characteristic. 

In the transverse laceration when cicatrized or only partly through 
the septum, the transverse groove in the base of the triangle can be 



DIAGNOSIS BY INSPECTION. 183 

easily felt and measured (Fig. 123). A cicatrized V-shaped laceration 
with a retracted angle or tongue of tissue often produces the same 
depression in the centre. 

When an uncicatrized transverse laceration with rectocele, or tend- 
ing to it, is present, the absence of the attachment of the levatores 
vagina? is known by the attenuation and want of resistance of the 
recto-vaginal angle of the perineal triangle when caught between the 
rectal and vaginal finger, and by the ease with which the base or vul- 
val side of the triangle or body can be swung or pulled outward under 
the pubic arch. By penetrating deeper into both vagina and rectum, 
the levator vaginae at the top of the rectocele can be caught between 
the ringers, and its length and resistance estimated by dragging it for- 
ward and from side to side and putting its pubic ends upon the 
stretch, so as to render them distinctly palpable. 

When a laceration extends beside the raphe the extent of tissue 
involved may be determined the same as if it were through the raphe. 

The strength of the perineum as a whole may be tested by approxi- 
mating the vaginal and rectal ringer at the recto- vaginal promontory 
and pulling them together in various directions, forward, backward, 
downward, from side to side, etc. We thus often find a small remnant 
of the perineal body quite firm and effective as a support. 

Diagnosis by Inspection. 

Inspection alone gives a less complete idea of the amount of perineum 
or pelvic floor injury than palpation. It however reveals the position, 
shape and extent of the cicatrix, and the amount of destruction, 
separation or distortion of the superficial landmarks. 

If the caruncles be continuous around the vaginal entrance, without 
an intervening scar, the laceration has not involved the vaginal orifices 
or levator vaginas to any considerable extent. If they be small and 
all or nearly all of them widely separated from each other around a 
gaping orifice that presents no scar tissue, there has been probably 
submucous diffuse laceration. If the cutaneous median line raphe 
extend up above the junction of the labia majora, the external perineum 
is not much affected. If the labia majora, however, pass straight 
downward and backward and do not converge to form a posterior com- 
missure, we know that there has been a median laceration. If the 
urethra and anterior vaginal wall sag down into the vulva, or the 
posterior vaginal wall project, we know that the parts about the in- 
troitus have been injured and imperfectly repaired, whether the vulva 
be firm and gaping or flabby and collapsed. If the perineum present 
the ordinary landmarks but sags downward so as to project farther 
than natural from the pubo-coccygeal line, or conjugate of the outlet, 
a general relaxation, diffuse submucous laceration, or transverse 
laceration may be inferred. 



184 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

As the labia are separated, evidences of a deep lesion will be in- 
dicated by the altered appearance of the deeper parts. If no signs of 
any tear be present, the sight may not be able to distingnish between 
the simple relaxation from the pressure of displaced organs that is not 
necessarily a result of parturition, and the diffuse submucous and 
uncicatrized lacerations due to labor. 

A unilateral or localized relaxation greater than that of the remain- 
ing parts, a participation of muscles distant from the vaginal orifice 
(as the sphincter ani), a greater relaxation or softness of the perineum 
than that clue to the amount of pressure of the displaced organs, and 
a want of retractability when these organs are supported, indicate the 
lacerated condition. Either a decided eversion or turning under of 
rugate mucous membrane at an edge of the scar, especially if the scar 
be angular, curved or unilateral, indicates a flap laceration. 

Combined Palpation and Inspection. 

Having determined by palpation what portions of the perineum are 
relaxed and out of place, and by inspection the superficial variations, 
we may by combining palpation and inspection find the relations of 
the cicatrices and superficial lesions to the relaxed or separated deeper 
structures. 

By everting the vagina by the finger in the rectum not only can 
the thickness and resisting power of the perineal body be estimated, 
but the cicatrices, stretched over the anal finger, appear blanched in 
the softer tissues beside them and can be traced to their minute ends. 
Hidden lesions may thus become plainly visible. Rectal eversion of 
the vaginal walls also informs us how high above the sphincter ani 
the perineal body supports the rectum, and of the extent of loss of the 
raphe above. 

Diagnosis of Old Lacerations Extending into the Rectum. 

The histor} r of fecal incontinence usually makes the diagnosis of 
laceration into the rectum an easy one. Upon palpation the rectal and 
vaginal outlets will be found to be in common. The perineal body 
will be completely divided and allow the finger to glide back along 
the pubic rami to the anus. At the upper and inner end of the lacera- 
tion the thin curved edge of the recto-vaginal septum will be felt about 
the median line ; or there may be a deep extension on one side, and a 
shallow one on the other, with a median projecting tongue of recto- 
vaginal septum between them. Inspection will reveal the red rectal 
mucous membrane posteriorly. 

Diagnosis of Lacerations of the Pelvic Floor. 

I. Of the Anterior Edge. — Lacerations of the anterior edge of the levator 
ani are accompanied by a relaxed levator vaginae and widening of the 



DEEPER PORTIONS OF THE PELVIC FLOOR. 185 

urethral notches, the more so on the side lacerated. The finger, in- 
stead of feeling the pubic attachment of the muscle near the internal 
edge of the pubic ramus, traces it upon the posterior surface of the 
bone and farther from the median line. The rectum at the recto- 
vaginal promontory is scarcely as prominent as normal and is flabbier, 
and makes a gentler backward curve, but it is more easily palpated 
through the relaxed tissues. 

II. Of the Levator Ani Proper. — When a large part of the levator ani 
proper is lacerated, the vaginal outlet is large and flabby, the recto- 
vaginal promontory thrown further back from the pubic arch toward 
the anus, and the most prominent part further in towards the coccyx. 
In lacerations involving the whole anterior section, or levator ani 
proper, the lower rectal curve (Fig. 31) is long and low instead of high 
and short, as it normally feels in the dorsal position. The urethral 
fossae are wide, and their lateral borders, usually formed by the levatores 
ani, feel soft and receding instead of hard and resistant. The rectal 
promontory and anterior edge of the levator ani are soft, flat and unusu- 
ally depressible and indefinite to the touch as far back as the coccyx. 
The rectal promontory as felt per rectum is almost or entirely absent. 
The posterior vaginal sulci or grooves are wide and often deep beside 
the flabby recto-vaginal promontory. The power of lifting this por- 
tion of the pelvic floor at will (by an effort to draw in or contract the 
anus) is diminished according to the amount of laceration. Finally, 
the most striking peculiarity in extreme cases is the pronounced pro- 
jection of the ordinarily buried tip of the coccyx, and of the ridge of 
levator coccygei fibres extending from the posterior surface of the an- 
terior pelvic wall near the anterior end of the white line on either side,, 
to the coccyx, and forming by their junction an angle or inverted V 
( A )• ^ ee Palpation of the Levator Ani, Chapter III.) Thus a very 
pronounced false promontory is found deep in the pelvis. If the patient 
is put in an uncomfortable position or requested to draw in the anus 
so as to hold back the fseces, this ridge will become hard if not already 
so. If the laceration be unilateral the rectum and ano-coccygeaL 
ligament will be drawn slightly toward the sound side. Such a com- 
plete relaxation of the levator ani proper is occasionally found without 
a tearing open of the rectum, and nearly always when the rectum is 
deeply lacerated. This condition was found four times in the series 
of cases already cited in this chapter, beside the case in which the 
rectum was lacerated. A failure to diagnosticate this kind of lacera- 
tion would be to fail in either understanding the symptoms or curing 
the patient. 

Deeper Portions of the Pelvic Floor. 

A generalized diffuse laceration (so-called overdistension) is known 
by the relaxation. (See Palpation of the Pelvic Floor, Chapter III.) 
Relaxation from laceration is usually unilateral or localized. Lacera- 



186 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

tion extending back into the levator coccygei fibres diminishes the 
size of the ridge on the lacerated side, or may place the anterior edge 
of the ridge back in the posterior section of the levator ani. 

If both sides of the muscle are torn to the same extent, the ridge 
will be less prominent, and displaced higher up and farther back on 
both sides. If the levator coccygei fibres be lacerated without par- 
ticipation of the anterior fibres of the levator ani, the vaginal entrance 
will be normal, but the recto-vaginal promontory will be high in front, 
but fall away more abruptly backward, and thus be narrow antero- 
posteriorly. The tip of the coccyx will not be as readily felt from the 
vagina as when the anterior muscles are lacerated. Unilateral lacera- 
tion of this portion alone increases the si'ze of the depression, or de- 
pressible area, corresponding to the obturato-coccygeus muscle, as 
compared with the sound side. The softened area is increased forward. 

Lacerations of the obturato-coccygeus are_nearly always unilateral, 
and are characterized by unusual softness of the fibres on one side, 
or an unusual prominence of the anterior edge of the coccygeus 
behind. If the tear extend into the coccygeus the greater sacro-sciatic 
ligament will be unusually high and prominent. Possibly a line of 
laceration or separation may be occasionally found. I have never 
found such, although I have in a few instances found the relaxed 
condition. A loosening or laceration of the fascia about the white 
line is known by the greater amount of curvature produced in it 
during voluntary contraction on one side. Sometimes a finger can 
be hooked into the curve, and almost get under its edge. 

In seeking for laceration in a relaxed muscle we must take the fact 
into consideration that extensive lacerations may, by removing fascial 
support, relax the whole pelvic floor. Voluntary contraction will 
often show which muscles are torn, and which merely relaxed. The 
first do not contract, the latter may. 

Unusual roominess of the upper vagina, with softness of the deeper 
pelvic floor musculature, unusual mobility of the cervix in a forward 
direction, a low position of the uterus, and a marked tendency of the 
abdominal walls above the pubes to sink back toward the promontory 
of the sacrum when the dorsal position is assumed, are general signs 
of relaxation of the pelvic floor from extensive injury. 

Method of Diagnosis. 

The finger should be so educated as to be able to recognize in a 
general way the presence and location of pelvic floor and perineal 
lacerations at the first touch. In passing into the genitals it should 
notice the amount and shape of the tissues at the fourchette, the con- 
dition of the hymen or caruncles, the depth and size of the pubic 
fossae, the size and shape of the urethral and rectal notches and vag- 
inal grooves or sulci, the height and width antero-posteriorly of the 



PREVENTION OF LACERATIONS. 187 

recto-vaginal promontory, and the absence or presence of an elevation 
of the tip of the coccyx and levator coccygei fibres. If we find the 
last-mentioned structures prominent, and the promontory flat, we 
look for a lacerated levator ani. If these parts are normal, but the 
parts below them relaxed, or otherwise altered in shape or relation- 
ship, the}^ should be more carefully examined, after the usual intra- 
pelvic examination has been made. It is well in all cases of multipara 
with a relaxed posterior vaginal wall to touch all of the principal 
landmarks of the pelvic floor in rapid succession, as it takes but a 
moment. (See Palpation of Pelvic Floor, Chapter III.) 

Prognosis. 

The chances for a complete ideal cure are favorable only by the 
immediate operation. After the time for that has passed, the shorter 
the delay after inflammation and suppuration have subsided, the 
better the opportunity for restoring the parts as they were before. 
The longer the separated parts are left to degenerate from loss of func- 
tion, and the longer the support to the inferior portion of the pelvic 
connective tissues remains impaired, the less chance is there to secure 
a normal coaptation of the parts that belong together, or to secure 
perfect union after such coaptation, or to relieve the effects of the long- 
continued laceration upon the surrounding tissue. Indeed, the re- 
sulting changes due to the laceration may finally become permanent, 
and be but little or very slowly benefited by perineorrhaphy. 

Prevention of Lacerations. 

The prevention of perineal and pelvic-floor lacerations should be 
studied in the works on obstetrics. Yet from the standpoint of the 
gynecologist, who is chiefly concerned with cases in which injury of the 
parts is pretty sure to result, it is well to give the matter a little farther 
consideration. The first thing to be thought of in such cases is to so 
manage the perineum and pelvic floor that they will, if lacerated, be 
in a condition for immediate successful repair, or an ultimate restora- 
tion of function. 

The management of the deeper pelvic-floor muscles consists mainly 
in securing a passage of the presenting part slow enough to allow of 
the requisite dilatation. Nature's way of doing this is by persistence 
of the bag of waters until they burst at the vulva. To imitate this 
natural mechanism the accoucheur has but to let things alone, and 
assist his patient to take things as easily and calmly as possible. The 
advice given by teachers and text-books to diagnose by palpating the 
fontanelles is harmful in its influence, and leads younger practitioners 
to spend a large part of the time of their attendance upon the confine- 
ment in poking the finger about in utero, bruising the cervix, and 
destroying the resisting power of the membranes. 



188 LACERATION OF THE PERTNEUM AXD PELVIC FLOOR. 

The next important service of the membranes is to prevent that 
superficial bruising and ecchymosis about the vaginal entrance which 
often lead to the deeply penetrating lacerations, and also the so-called 
inevitable one. Another is to provide the wedge to prepare the vulval 
and vaginal rings for the head. 

When the membranes do not persist long enough, a slow advance 
gives time for the formation of a caput succedaneum, which will act 
as a wedge in the vaginal and vulval outlets (Dumas) in place of the 
membranes. A rapid advance over the deeper parts leaves the caput 
succedaneum to be formed after, instead of before, the whole perineum 
is pressed upon and bruised, and thus often too late to prevent the 
laceration. 

"When the normal method of dilatation of the pelvic floor and 
perineum does not occur, the assistance of the accoucheur must sup- 
ply the wedge, the restraining force, and the directing force. The 
latter is lost when the perineum is not normally folded at the four- 
chette, so as to give the proper slope to the pelvic floor (Figs. Ill and 
124). As we work for a vigorous condition of the parts after labor, we 
should not supply this force by pressing upon the perineum in front of 
the anus, nor by fingering the delicate rectal walls, but should choose 
the post-anal cutaneous surface for pressure, as was taught by Eitgen. 
If the head needs also to be temporarily retarded, the finger of the 
unemployed hand may be passed into the vulval or vaginal entrance 
instead of being placed against the perineal body. If the perineum 
be not too rigid the fourchette and posterior commissure may be 
digitally drawn back toward the anus at the beginning of the pain, 
and the raphe be held back until, but only until, the head advances 
upon it. This is necessary where there is a tendency to a wide sepa- 
ration of the vulval and vaginal rings (Fig. 112) threatening a diastasis 
of the muscles, or a transverse perineal laceration. Should, however, 
too much be attempted in the way of digital dilatation, the perineum 
will be bruised, and the condition we are so anxious to prevent will 
be produced. 

Rather than delay the head after it be determined that laceration 
must eventually occur, we should deliver it before too much bruising 
has taken place, thus precipitating the laceration at a time when its 
immediate repair can be successfully accomplished. But as a lacera- 
tion heals less perfectly by first intention than a well-chosen incision, 
it may sometimes be better to perform colpotomy, episiotomy or 
perineal tenotomy. 

Perineal Incisions. 

In imitation of nature's method of relaxing the perineum by a 
laceration through the smallest of the perineal rings (the obstructing 
one), it has been proposed to make an incision through the internal 



COLPOTOMY — EPISIOTOMY. 189 

perineal ring or levator vaginaB (colpotomy) or the external perineal 
ring or constrictor cunni (episiotomy), according as one or the other 
fails to exhibit the requisite distensibility for the passage of the head. 
Considerable judgment must be used in performing either of these 
operations, for from the moment the incision is made a weak point is 
created which will lacerate deeply under strong pressure. But little 
more stretching can then be expected, and the dilatation of the orifice 
will be in proportion to the depth of the incision. Therefore, if the 
ring be not already dilated almost to the required extent, the incision 
will be inadequate, and will be enlarged by tearing, and may even 
extend into the rectum. The only laceration into the rectum of the 
series reported in these pages occurred after an incision in the 
perineum.* On the other hand, if we wait too long the parts may 
become too much bruised for primary union. Hence the proper time 
is as soon as the ring has ceased to enlarge — or enlarges so slowly that 
but little more dilatation can be expected — and before complete dry- 
ness and numbness of the vaginal entrance has occurred. 

Colpotomy. 

The place for the incision is at one side of the median line, and the 
greater the amount of dilatation required the farther to the side should 
be the incision. Its direction should be diagonal, extending forwards 
towards the median line intersection of the external or constrictor 
cunni ring, or fourchette. When one incision does not afford the re- 
quisite amount of dilatation, another on the opposite side may be 
made. By rectal indagation between or just after pains we may ascer- 
tain by the direction of the raphe, which is easily recognized on the 
anterior rectal wall, the side that is stretched the most and make an 
incision accordingly. I prefer to cut first on the least dilated side, as 
that part is the less bruised and will have less traction upon it when 
united subsequently. 

A straight blunt-pointed bistoury is the best instrument for the 
operation, although a pocket-knife may be used. Just as a pain is 
subsiding the left index finger should, as soon as it can find room, be 
slipped between the ring and the head, and the incision made with 
the other hand into the edge of the ring as held tense by the head and 
finger. Care should be taken not to extend the incision along the su- 
perficies any farther than necessary, as such extension would increase 
the size of the wound without aiding in the dilatation. 

Episiotomy. 

When the constrictor cunni is the unyielding part of the perineum, 
or when the levator vaginae and hymen have been so slow in dilating 

* Patient's testimony. 



190 LACERATION OF THE PERINEUM ANI) PELVIC FLOOR. 

that any further bruising must destroy the elasticity of the parts, 
episiotomy may be performed. It is clone at one side of the median 
line, but not so far to one side as colpotomy. The incision or incisions 
are also less diagonal, and extend or converge toward the posterior 
commissure of the labia majora. Care must be taken not to incise the 
labial ring, for the skin, if given time, will almost always stretch 
sufficiently. 

Perineal Tenotomy. 

When the dilatation has reached such a degree that one incision will 
afford all of the dilatation needful, then perineal tenotomy, or an in- 
cision into the median line raphe or tendon, is preferable. According 
to the place and amount of such incision the superficial, the deep or 
the whole perineal tissues (muscles, fasciae and superficies) can be re- 
laxed. The disadvantage of perineal tenotomy is that it cannot be 
• 

Fig. 124. 



'posterior vaffinaL 
Wall » ^ 




~Perbyvfal 

booby 



Incisions to be made in Perineal Tenotomy.— Compare with Figs. 32 and 111. 

c, anterior edge of constrictor cunni (fburchette) ; I, anterior edge of levator vaginae ; ac, depth 

of large incision, and course of tenotome in the subcutaneous incision ; da, incision for relaxing 

levator vagina? et ani ; b c, incision for relaxing constrictor cunni and slightly the levator vagina?. 

made to relax any one ring quite as much as the other operations. 
Its chief advantages are that with a moderate incision it can be made 
to relax the whole perineum better, and that the stitches draw together 
the whole perineum more nearly as it was before. 

The operation may be performed very much as is colpotomy (p. 189), 
except that the incision must be made in the median line. If the 
vaginal or internal perineal ring be the part chiefly at fault, the inci- 
sion is mostly vaginal and should penetrate into the tissues until an 
appreciable relaxation is produced ; if the vulval rings be the offending 
ones, the incision should be mainly in the vulva; if the whole peri- 
neum be rigid, the incision should be through both. Fig. 124 shows 
by curved lines the place and extent of the incisions. The interrupted 
lines show the extent of the smaller incisions. In order to avoid 
wounding the rectum, its course should be determined by rectal inda- 
gation. 

When the conditions are favorable the tenotomy should be performed 



PERINEAL TENOTOMY. 191 

subcutaneously and antiseptically. At the subsidence of a pain the 
rings are held by the index placed at one side of the median line, and 
if necessary the middle finger at the other. A very narrow tenotome 
should be used whose blade or cutting portion is no more than a half 
inch in length (Fig. 125). For relaxation of the whole perineum the 
blade should be entered flat (with cutting edge turned to one side) just 
external to the ring of the constrictor cunni (Fig. 124, c). The blade 
point should pass straight clown almost parallel with the posterior 
vaginal wall, or deviating slightly toward it, for half an inch. Then the 
cutting edge is turned backward toward the vaginal wall and the point 
carried to a point in the vaginal wall opposite to, or back of, the ring 
of the levator vaginae (b or a) according as much or little effect upon 
the internal perineal ring (I) is desired. When the vaginal finger 
placed over the vaginal portion of the raphe feels the point of the in- 
strument under the mucous membrane, the knife is thrust no farther 
but is made to cut upward through the raphe at the same time that 
it is being withdrawn. If, however, the point of the knife makes an 
appreciable wound through the vaginal mucous membrane, the re- 

FiG. 125. 




Perineal Tenotome. 

mainder of the incision should be out through the mucous membrane 
and vulval skin, so as to make an open wound of it. If the constrictor 
cunni be dilatable, the tenotome should be entered internal to the 
muscle (at d). The knife enters along the curved lines representing 
the bottom of the incisions in Fig. 124, and makes about the same-sized 
wound as in the other method, but the cutting is upward instead of 
downward. The knife may in some cases be passed the required depth 
under the vulval skin and mucous membrane and the cutting be made 
just toward instead of from the perineal centre. We can then stop as 
soon as we feel the desired amount of relaxation to have occurred. It 
is also possible, by introducing the knife nearer the posterior commis- 
sure or labial ring and giving it a direction parallel with the skin, to 
divide the perineal centre, or attachments of the transverse perinei 
above the sphincter ani — but such is seldom necessary. 

Just before operating the parts should be well cleansed, and the 
knife and fingers, after also being cleansed, dipped in a five per cent, 
aqueous, or ten per cent, oleaginous, solution of carbolic acid, or their 
equivalent. Immediately after operating the parts should be kept 



192 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

compressed between the thumb and fingers, to prevent hemorrhage, 
and two or three applications of collodion be made to close the opening. 
As soon as the head advances the fingers may be taken out of the 
vagina, and the parts pressed against the head. Should the head 
recede too much between pains to allow of such pressure, it can be 
held down against the perineum by the fingers placed in front of the 
coccyx. An anaesthetic, local or general, will oftener be required in this 
last operation than in the others, which are less delicate. 

Delivery after Perineal Incisions. 

After the perineum has been incised it must of course be carefully 
managed. The directing and restraining forces must be supplied by 
the accoucheur, and the head slowly and carefully delivered between 
pains. An anaesthetic should be given to the extent of suppressing 
voluntary efforts, unless the co-operation of the patient can be obtained. 

Choice of Methods. 

When the levator vagina? cannot be safely dilated to form a ring 
three inches in diameter, bilateral colpotomy should have preference 
over the other incisions, since a median incision of moderate size could 
scarcely afford the requisite amount of dilatation. When the diameter 
of the ring reaches three inches and the head has rotated almost or 
quite to the median line, a median incision or tenotomy is the prefer- 
able procedure. This last incision should extend through the ring of 
the constrictor cunni in case that muscle is also un dilated. When in 
addition to the bilateral colpotomy the constrictor cunni also needs 
relaxing, the diagonal incisions may be made to meet at the ring of 
that muscle, and be extended slightly downward through the raphe, 
thus completing the Y. Or, when the ring of the levator vagina? is 
three inches and that of the constrictor cunni requires a slight incision, 
the diagonal single incision may take a direction toward the posterior 
commissure and pass through both rings. Thus the two operations 
are performed by a single cut (colpo-episiotomy). This does not 
prevent us from making another diagonal incision on the other side, 
and is the operation most usually performed under the name epis- 
iotomy. 

When the levator vagina? is almost or quite dilated or dilatable, and 
the constrictor cunni is entirely at fault, the best method is to incise the 
raphe, and if the levator vagina? be then found to afford resistance, to 
extend the cut backward. A rigidity of the external muscle precluding 
a safe dilatation to a diameter of three inches would make it necessary 
to extend the median incision to the perineal centre (at the meeting 
of the transverse perinei) and would call for a bilateral episiotomy. 



TREATMENT BY COAPTATION. 193 

After Management. 

Incisions passing deep into the raphe, or more than half way through 
the belly of a muscle should be united soon after the labor is completed. 
Slight subcutaneous incisions in the raphe may be left alone ; deep ones 
should be sewed up along the line of incisions by deep stitches. One or 
two vulvo-vaginal and possibly a cutaneous stitch will be needed. Silk- 
worm gut taken directly out of a five per cent, solution of carbolic acid, 
and introduced with aseptic precautions, is preferable as being noncon- 
ductive of germs, and subsequently unirritating. It may be removed 
on the fourth or fifth day. The puncture made by the tenotome is to 
be kept closed by a stitch or covered by the flexible collodion. 

Treatment of Perineal Lacerations. 

Immediately after labor a laceration may be united by sutures, 
by coaptation, or treated as an open wound. After the wound has 
healed without restoring a satisfactory condition of the parts, the only 
treatment left is by support or by secondary perineorrhaphy. 

Superficial Lesions. 

Wounds that do not extend into the muscles or raphe should be 
treated upon the same principles as open wounds upon any other 
part of the body. 

Treatment by Coaptation. 

The great majority of gynecologists of to-day advise the suturing 
of extensive perineal lacerations after labor; yet there are some of the 
best authorities, such as Fordyce Barker and Charpentier, who advise 
against operative measures. 

Charpentier* washes off the wounded surfaces, carefully places them 
in accurate coaptation, ties the thighs together and then keeps the 
patient on the back. A compress dipped in a one per cent, solution 
of carbolic acid is kept against the perineum, and the parts gently irri- 
gated with the same solution four times in the twenty-four hours, and 
also after urinating. The bowels are controlled by opiates until the 
fourth day, when a dose of oil is administered. At the end of forty- 
eight hours the patient is placed for the first time on her side and the 
edges of the wound examined. He has always found union by first 
intention in the posterior part of the cutaneous wound,, followed by a 
rapid closure of the remainder. After, the examination the thighs are 
again tied together by a ribbon. 

As the posterior part of the tear, viewed externally, is often only through the skin 
and fat ; as this is the only place where Charpentier claims to get union by first inten- 
tion ; as no mention is made of the parts in the vaginal entrance whose restoration 

* Traite" des Accouchements. 
13 



194 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

is of the greatest value ; and as he seems to regard a cicatrized perineum all that is to 
be desired, it is impossible to consider his success so satisfactory that all attempt at 
anything better should be abandoned. 

Immediate Perineorrhaphy. 

The following personal observations have long since led me to regard 
the immediate repair of extensive perineal lacerations by suture not 
only a benefit but a necessity to the parturient woman. (1) When 
the laceration is sutured, union by first intention occurs as far forward 
as the front stitch and no farther (thus proving the action of the stitch) ; 
the resulting perineum is as large and complete in most cases as that in 
the nullipar; even when only partial primary union is obtained, the 
support to the contiguous parts of the pelvic floor is such as to restore 
to it and to the vagina their previous tonicity and vigor. (2) When 
not sutured the perineum is scarcely ever normal or complete. Flaps 
of mucous membrane and ends of fasciae, muscles and nerves are drawn 
down into the cicatrices instead of being drawn to the parts from which 
they were severed ; cicatrization may not occur ; either subinvolution 
or atrophy of tissues is apt to result. 

The fact that the majority of cicatrized lacerations do not require a subsequent opera- 
tion is no proof that the parts would not be in a better condition if they had been 
successfully repaired by the primary operation. The chief reason why a secondary 
operation is often not advisable is that the harm has all been done, and the operation 
would put the patient to considerable expense and trouble without undoing that harm 
to a compensatory degree. 

Reasons for Failure of the Immediate Operation. 

The reason why the immediate operation has shown so unfavorably 
is because of poor surgery. Superficial parts alone have been united, 
edges have been pared so that the subsequent retraction has drawn 
upon the stitches, proper coaptation has not been attempted, and the 
wound, although in an unfavorable place for cleanliness and aseptic 
treatment, has not received even the ordinary attention given to wounds 
in other parts of the body. Let the care be given that Charpentier 
recommends for those not sutured, and the results will give no cause 
for complaint. 

Co n traindications. 

As a rule it is useless to sew a perineum upon which the head has 
impinged for hours, since capillary extravasation of blood has occurred 
and subsequent inflammation, suppuration, necrosis of tissue, one or 
all, may be expected to result. To operate under such circumstances 
without success is the fault of the operator. The quicker the passage 
of the head the better the chance of primary union. 

A general condition of the patient that would prevent primary union, 



THE OPERATION. 195 

and circumstances that interfere with appropriate after-treatment are 
also counterindications. 

The Operation. 

The operation for immediate perineorraphy consists in a neat and 
accurate closure of the wounded surfaces so that every part lies in di- 
rect but unconstrained contact with that from which it was separated. 
A needle, silk thread, a pair of scissors, and a few strips of old linen or 
muslin cloth, are necessary. A needle-holder, silkworm-gut, two or 
three sharp hooks, a powder-insufflator, iodoform, carbolic acid, lint, 
absorbent cotton, etc., are desirable. 

I generally use a semicircular needle 2J inches long and 1\ from eye 
to point, threaded with 12 or 14 iron-dyed silk, or with coarse silk- 
worm gut, or hardened catgut. A small piece of old muslin, wrapped 
around the blunt end of the needle, may serve as a needle-holder. 

As soon after labor as the patient can be made clean, not later than 
twelve or fifteen hours, she should be placed across the bed on her 
back with the hips at the edge, and the knees held up or elevated. 
The parts are often so numb that the operation is not painful, yet in a 
few instances an ansesthetic may be required. A few drops of a fifteen 
per cent, solution of cocaine applied to the wounded surface and around 
the edges by a pledget of cotton, and repeated in four or five minutes 
has sometimes enabled me within ten or fifteen minutes to obtain com- 
plete local anaesthesia. The vaginal contents are first allowed to flow 
out, and then a piece of absorbent cotton or soft muslin stuffed into the 
vagina and the cocaine pledget placed in the wound. 

After clipping the hairs from the labia, wiping out the vaginal en- 
trance, inspecting the wound and paring any ragged edges, some fresh 
strips of soft cloth, a wad of absorbent cotton, or a small sponge should 
be introduced beyond the rent. Before the stitches are introduced 
the edges should be brought together to show just how they belong. 
Whether vaginal portions be diagonal or median, enough vaginal 
stitches should be used to coapt the edges perfectly. The point of 
the needle should be introduce^ about one-thirty-second of an inch 
from the edge of the wound, should pass not parallel to its surface, but 
slantingly so as to grasp deeply into the retracted ends of the torn 
fibres of the levator vaginae and levator ani, then out over a small 
strip of the bottom of the wound, into the tissues opposite the point of 
exit and out again through the mucous membrane exactly opposite its 
first entrance. The finger should be introduced into the rectum when 
a deep stitch is introduced in order to avoid including it. It is usually 
most convenient to introduce the first stitch in the upper end of the 
wound. If we have no sharp hooks or cannot, on account of the 
rounded edges (Fig. 117), determine just where the upper angle should 
be, we can put in a stitch just behind the carunculse and, without tying 



19*3 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

it, use it to draw the laceration into better shape. If we find a double 
diagonal laceration with a forward extension through the vulva, we 
may introduce a stitch from the external skin along the extreme upper 
edge of the tear on the left side, bringing it out at the angle of junction 
of the median and transverse portions, catch it into the fibrous coat of 
the projecting tongue of the lacerated posterior vaginal wall in the 
median line, and bring the point across to the opposite labium and out 
through the skin of the upper edge of the tear. This stitch, like all 
others taken from the skin, should enter near the edges of the wound 
and pass deep into the sides in order to include and draw together the 
deeper and more important tissues. It should not be tied until the 
last, but may be made to draw the wound together and show where 
the other stitches belong. When the stitches are passed in this way 
near the edge, there is less tendency to compression, eversion and sup- 
puration. Fig. 126 shows the stitch thus passed; Fig. 127, passed in 
the ordinary way. Fig. 127 also shows why it is sometimes necessary 

Fig. 127. 





Fig. 126.— a. Deep Suture entered near edge of Wound to avoid Eveision and Compression; 6, 
same, tied. 

Fig. 127.— a, Deep Suture entered at a distance from the edge of Wound , b, The Same, tied . Com- 
pression of edges and tendency to eversion above the interrupted line. Primary union is apt to 
fail above this line. 

to pare the edges of the wound, as in Fig. 1 28, to prevent constric- 
tion, eversion and want of union of the surface, and explains the 
paradox that to cut away the edge gives a thicker perineal body. 

As each stitch is passed, starting at the upper end, the raw surface 
should be thoroughly cleansed, and, if practicable, touched with a three 
per cent, solution of carbolic acid or one two-thousandth solution of cor- 
rosive sublimate, or dried and sprinkled with iodoform, and the stitch 
tied tight enough merely to draw the parts together. The anterior ex- 
ternal stitch must be the firmest, since that one sustains the chief strain 
and protects the others. 

Vaginal lacerations in the median line may be united by a few fine 
stitches or a continuous catgut suture. Flaps in the vulva and va- 
ginal entrance are similarly stitched to the opposite side from which 
they were torn, and the sides of the open cavity under them brought 
together by the deep cutaneous sutures. Thick flaps are best united 
by Tait's flap stitch. The needle is passed into the flap at the edge 
of the mucous membrane or skin, through almost its entire width, 



THE OPERATION. 197 

then out across the bottom of the wound, into the opposite side, and 
out again at the edges of the mucous membrane opposite its first intro- 
duction. Fig. 129 gives a profile view of the stitch passed. 

If the sphincter ani is not ruptured, I first place the upper external 
stitch at the very upper end of the laceration and draw the parts to- 
gether. It will then be easy to see just where to put the next one and 
how deep it need be to entirely close the wound. One stitch at the 
top will seldom hold the ends of the transversus perinei unless it be 
placed too low to keep the upper edges together, hence two or three 
must generally be used. 

If the sphincter ani be lacerated the first external stitch should be 
devoted to it, and should grasp deeply into it so as to include the 
fibres at the bottom of the wound and thus bring the whole muscle 
together. The next stitch should be a little above it, and should reach 

Fig. 128. Fig. 129. 






Fig. 128.— a, Edges of Wound Pared to prevent compression by stitches and suppuration of edges. 
b, The same, tied. 
Fig. 129.— Flap Stitch, entered into edge of Flap and brought out at opposite edge of Wound. 

out well into the retracted tissue to get a good hold upon the trans- 
versus perinei and restore the perineal centre. One or two deep ones 
above these will usually close the wound completely, provided the 
vaginal stitches have been placed. 

When thus perfectly coapted under thoroughly aseptic precautions, 
the parts adhere almost immediately, and are quite firm in four or 
five days, and as there is an abundance of tissue about the puerperal 
genitals there will be but little traction until the union will have 
become firm. 

Although silkworm gut is hard to tie properly, I prefer it for the main 
vaginal stitches, and leave it from ten to fifteen days, or until the 
perineal body is firm. Well-prepared catgut is more easily used, and 
just as efficient for the higher vaginal stitches provided the lower and 
external ones are properly placed so as to sustain all traction. I have 
frequently used silk for all sutures, removing them in four or five 
days, with equal success. Waxed silk sometimes gives pain in passing 
through the tissue, but is easily tied, and the best adapted for the flap 
stitch. There is no object or justification in putting the woman 
through the mild but prolonged torture attending the use of silver 
sutures. 

When the parts are properly united the after-treatment is more 
watchful than active. The knees are bound together so that they 



198 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

cannot be separated more than ten or twelve inches, and the perineal 
skin covered by a folded piece of iodoform gauze, or lint soaked in a 
ten per cent, solution of carbolic acid in castor oil. The vulva is 
cleaned three times a day by squeezing hot water over it from a sponge, 
and also each time after the patient urinates, or is catheterized. With 
such precautions she may urinate in a flat bed-pan from the begin- 
ning. On the third day I commence vaginal injections of hot water, 
substituting a two per cent, solution of carbolic acid as soon as there 
be found a decided odor or appearance of pus in the discharges. The 
parts should be inspected in a good light on the third and each suc- 
ceeding day or two. On the third or fourth day a dose of castor oil 
or a mild saline is given. On the fifth all silk stitches are removed 
and the knees liberated from the bandage, but the patient forbidden 
to separate them. If silkworm-gut stitches have been used, they need 
not be removed for several days or a week later, unless they are too 
tight and commence to ulcerate. 

Frequently, however, there is more to do than this. The inflamma- 
tory reaction may go on to suppuration. If so, after each carbolated 
douche the labia should be separated, and the edges of the wound 
washed and touched with a five per cent, solution of carbolic acid or 
sprinkled with iodoform. If pus come from the vagina a three per 
cent, solution may be thrown in upon the stitches with a little piston 
syringe, after having placed a little cotton on the meatus urinarius to 
protect it. A very small strip of lint dipped in carbolated oil, but 
squeezed out so that the oil will not get on the urethra, should be laid 
over the edges of the wound in the vulva, and on the external cuta- 
neous surface. The parts should be thus dressed twice a day except 
that a three per cent, solution of carbolic acid will be strong enough 
after the first dressing or two. If the suppuration increases the parts 
should be dressed every eight hours. 

After the stitches are removed the wound should be cleansed with 
the carbolated water and protected with the carbolated oil or lint 
three times a day, until suppuration has pretty well ceased, then twice 
a day. In this way, even when the condition is not favorable, I 
always get union of the deeper and important tissues by first inten- 
tion, and usually of the whole. In most cases in which the stitches 
include much skin, as in Fig. 127, there will be a little suppuration 
in the fatty tissue about the external cutaneous edges, and occasionally 
a little about the bruised edges near the hymen, which scarcely ever 
diminishes the length, but may slightly diminish the thickness of the 
resulting perineal body. 

I have twice introduced a deep stitch to hold granulating perineal 
surfaces together, but have only produced irritation and increased 
suppuration, and now content myself with binding the knees and 
dressing the surface as an open wound. If, however, we have a nurse 



SECOND AKY PERINEORRAPHY. 199 

who will thoroughly and frequently syringe out the depression or 
gutter between the wounded surfaces, the granulations may be ex- 
pected to meet and unite more quickly, and draw the parts in better 
shape, than without the stitch ; but without such attention the inclosed 
pus decomposes and does harm. 

Lacerations into the Rectum. 

I have not yet had an opportunity to sew up a laceration opening 
into the rectum by immediate operation, but consider that the advan- 
tages of an immediate operation are greater for such a lesion than for 
the incomplete variety. As such a laceration usually occurs rapidly, 
and before much dilatation of the inferior parts, the probabilities are 
that the amount of bruising will not usually be sufficient to prevent 
union by first intention. The edges should be trimmed perfectly 
smooth, the parts drawn together by hooks, and the shape of the tear 
accurately determined. The rectal mucous membrane is then united 
accurately by a continuous catgut suture, or a series of silkworm-gut 
interrupted sutures, which include but little beside the rectal mucous 
membrane. The remainder of the rent is then united as directed for 
lacerations not extending into the rectum. It must be borne in mind 
that no traction is allowable on the rectal stitches ; the vaginal and 
cutaneous must be depended upon for holding the parts together. 

The after-treatment is the same as for the lesser lacerations, except 
that the bowels are kept constipated for four or five days at least, and 
not disturbed by a laxative unless a rectal pressure is complained of 
by the patient. The less opium that accomplishes the purpose the 
better. In finally moving the bowels I prefer to give five or six grains 
of blue mass, followed, if necessary, in twenty-four hours by a mild 
saline, so as to give time for a softening of the faeces. If lumps are 
felt in the rectum they should be broken up against the sacrum by 
the well-oiled finger introduced along the posterior rectal wall. As 
rectal tubes or catheters are liable to be directed by the rectal promon- 
tory forward against the wound, they should not be used except by 
the physician. (See Figs. 31 and 54,) The silkworm-gut vaginal 
stitches should be allowed to remain for two or three weeks, and if 
not easily accessible without stretching the parts, may be left two or 
three weeks longer. 

Secondary Perineorraphy. 

An ideal secondary perineorraphy should be the same as the imme- 
diate operation, with the additional preliminary step of cutting out 
the cicatrices, and denuding the tissues that were exposed at the time 
of the laceration. That the older methods of restoring the vulvo- 
vaginal outlet and forming a new perineal body were unsatisfactory, is 
attested by the number, complication, and confusion of methods that 



200 LACERATION OF THE PERINEUM AXD PELVIC FLOOR. 

have been recommended. The first and fatal fault consisted, and still 
consists, in treating the perineum as so much plastic tissue to be cut 
and fitted as a tailor fits a coat. For the sake of simplicity it is also 
customary to recommend one form or fashion of perineorraphy as the 
usual operation. It would be much more reasonable to recommend, 
for the sake of simplicity, one amputation of the leg for all kinds of 
injuries requiring an amputation, for the leg is a much simpler struct- 
ure than the perineum. 

What is to be Accomplished. 

It is not only necessary to remove a cicatricial tissue and unite torn 
surfaces in performing perineorraphy, but to so unite them that the 
characteristics of the perineal body will be restored. The recto-vaginal 
promontory must normally close the pelvic outlet. The V-shape of 
the edge of the levator ani, the sling shape of the levator vaginae, the 
convergence of the labial tissues at the fourchette, the size and pyra- 
midal shape of the perineal bod}', and the approximation of the 
median line attachments of the levator vaginae and constrictor cunni 
to the perineal septum, are all to be restored. 

When to Operate. 

The operation should be performed as soon as the parts can be 
brought into a healthy state and the patient's general health will per- 
mit, for the longer the delay the greater the reaction and atrophy of 
tissue, and the less the chance of restoring the contiguous unsupported 
deeper parts to their normal place and condition. (See Prognosis.) 

Methods of Restoring the Perineum when the Rectum is not Opjened. 

From the time when perineorrhaphy meant the denudation and 
uniting of a narrow strip of labial tissue there has been a long series 
of operations devised, many of which still survive as useful thera- 
peutic measures. Yet none of them has, or can, become the one ideal 
operation. 

The Median Triangular Operation. 

The oldest of the surviving methods of closing the rent is by a 
triangular denudation. A line is drawn along the edge of the skin 
external to the laceration from a point on one labium major above 
the lacerated portion to a corresponding point on the other labium, 
and two other lines joining the ends of this line to a point in the 
median line of the posterior vaginal wall above the cicatrix or relaxed 
portion (Fig. 130). The surface included in these lines is to be 
denuded. Two denuded triangles are thus formed whose common 
base (the dotted line) is the median line. They to be brought together 



THE MODIFIED TRIANGULAE OPERATION. 



201 



so that the labial angles (I I) will meet, and be so stitched by vaginal 
and cutaneous stitches. By comparing Fig. 130 with Figs. 114 and 115 
it will be seen that the denudation corresponds with the appearance of 
certain median lacerations after labor. This is the ideal operation in 
median lacerations of the vulva with but little or no extension into 
the vagina. But as such lacerations seldom require attention after 
having cicatrized, the operation is seldom to be performed. 



The Modified Triangular Operation. 

In extending the denuded triangles far enough up the posterior 
vaginal wall to cover a median laceration extending through the levator 
vaginas, it has been found that the traction upon the stitches at the in- 
troitus vaginae prevents primary union between them. In consequence 
a pus pocket forms at the recto-vaginal promontory and a subsequent 
depression remains at or in front of the recto-vaginal promontory 



Fig. 130. 



yburin& 




Fig, 131. 




Jkin 



^t'djiws 



Triangular Denudation (Schematic). 
vv, vaginal stitches, not always required 
ccc, cutaneous stitches ; 1 1, labia. 



Modified Triangular Denudation (Schematic.) 
lv, anterior edge of the levator vagina. 



something like that in Fig. 123. Too much of the levator vaginae has 
been excised and the perineal body is of course but imperfectly re- 
stored. 

In order to obviate this the triangles are made to extend only to the 
levator vaginse, and a smaller triangle or notch is denuded on the 
posterior vaginal wall as far as desirable. Fig. 131 shows the triangle 
thus modified, Fig, 132, the surface as it appears between the labia. 

The reason why the raw surface in the secondary operation is nar- 
rower than that found immediately after the laceration has occurred, 
is because the parts are, in the latter case, all drawn apart to an equal 
degree for inspection, whereas when cicatrization occurs the edges of 
the shallow and but slightly retracted vaginal portion are drawn over 
the wounded surface in a proportionately greater extent than those 
of the many times deeper and strongly retracted vulval portion. 

This operation is then the ideal one for median lacerations extend- 
ing up the posterior vaginal wall. But the proportion of such extended 
median lacerations requiring a secondary operation is small. 



202 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



The Bilateral Operation. 

Having noticed from a study of the cicatrices that lacerations extend- 
ing beyond the vaginal entrance assumed a diagonal direction on one 
or both sides instead of following the median line. W. A. Freund rec- 
ommended to extend the vaginal triangles or tongues along the cic- 
atrices on either side, and leave the sound vaginal wall about the 

Fig. 132. 




Appearance of the Modified Triangular Denudation as viewed between 
the separated Labia with stitches passed (Zweifel.) 

median line. As the cicatrix does not always represent the entire ex- 
tent of the tear, he removes sufficient tissue around it to normally close 
the vaginal orifice. The resulting raw surfaces have almost the same 
shape as that which is found immediately after the laceration. Com- 
pare Fig. 117 with Fig. 133. The edges of the vaginal denuded strips 
are first drawn together (Fig. 134), and afterwards the resulting vulval 
triangles. Even when one of the arms of the Y is almost or entirely 
wanting in the cicatrix, a short strip must be denuded in order to 
bring the parts together symmetrically. For instance, if the shorter 
vaginal strip were entirely gone in Fig. 133, and the edge of the 
denuded figure were at the dotted line instead, it will readily be seen 



THE BILATERAL OPERATION. 



203 



that the edge of the vaginal portion on the side of the dotted lines 
would be too long for the other side. 

This method is the ideal one for the incomplete Y-shaped lacerations 
which are so frequently met with. Martin has modified Freund's me- 




Fig. 134. 




7ft- Amxs $& Jteus 

Bilateral Denudation with stitches passed. The Same, with Vaginal Stitches tied. 

vvv, vaginal stitches ; ccc, cutaneous stitches ; I, labia. 

thod by extending the vaginal tongues deep into the vagina and the 
vulval denudations higher up. It is, however, intended more as an 

Fig. 135. 




Martin's Modification of the Bilateral Denudation. 



operation for prolapse when the parts cannot be permanently restored 
to their normal relations, and gives a small firm vaginal entrance. 
(See Fig. 135.) 



204 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



Crescent Operation. 

As in many cases the vaginal entrance only is lacerated, the cicatrix 
may be removed and the lacerated parts united by removing a crescent 
from the vulvo-vaginal entrance whose angles extend into the posterior 
vaginal sulci or grooves (Fig. 136). The centre of the convex external 
edge of the crescent reaches almost or quite to the fourchette. The 
centre of the concave inner edge is at the lower end of the sound 
posterior vaginal walls behind the cicatrix, or in the absence of a 
cicatrix it is located just below the median line attachment of the 
levator vaginae. The angles of the crescent include the cicatrices of 
the diagonal laceration. 

The stitches are so placed as to draw the two edges together com- 
mencing at the angles (Fig. 137). When they are drawn together a 
labial notch is left from the longer side of the crescent to be united by 
one or more sutures. 

This is the ideal operation for the V-shaped lacerations. It draws 
together the torn edges of the levator vaginae, or shortens it if it be 



Fig. 136. 



Fig. 137. 



Fig. 138. 







yyytenf 



%*. 



3VU.S 



Zfrv&JZTtS 



4M 



'JtlCS 



Fig. 136.— Crescentic Denudation with Vaginal Stitches passed. (The laceration is supposed to 
have been larger on patient's left side.) 

v, vagina; ss, sulci of post- vaginal wall. 

Fig. 137.— The Same, with Vaginal Stitches tied. 

Fig. 138— Crescentic Denudation modified to close a Transverse Laceration without narrowing 
the Vulva. Same lettering as Fig. 136. (The laceration is a little larger on left side (of patient) 
than on right.) 

relaxed from diffuse laceration ; it restores the recto-vaginal end of the 
raph6 ; and it brings together the separated ends of the constrictor cunni 
in case that has been reached by the tear. Much or little vulval tissue 
may be included, and the labial notch left after passing the vaginal 
stitches may be increased if the vulva remain too much relaxed. 

When the V is very wide open or the rent is a transverse one with 
a slight diagonal extension on either end ( v^r ^— •), it is better to 
place the ends of the external convex curve low down at the outer 
side of the sulci, and make the inner curve pass deeper into the sulci 
and then turn back to meet it. Thus the inner side, by the extra con- 
vex curve at each end, becomes as long as the external side, and may 
be united without leaving a redundancy anywhere (Fig. 138). 



EMMET'S CRESCENT OPERATION — STAR OPERATION. 205 

EmmeVs Crescent Operation. 

Emmet operates upon posterior colpocele and rectocele by drawing 
without undue traction the crest of the rectocele and the two lower 
caruncles together by tenacula, denuding the tissue thus folded 
together as far into the sulci as the folds extend, and uniting the edges 
of the resulting figure in the shape of a crescent by stitches " passed 
in a direction from the centre towards the circumference,"* somewhat 
as in Fig. 137. 

This operation holds about the same relation to the operation just 
described as Martin's operation does to Freund's. It removes the 
vaginal tissue that cannot be replaced and closes the vaginal entrance 
to the desired extent. Its chief peculiarity is that it unites the ends 
of the levator ani (from which a median piece has been removed) to 
the vulval tissues, instead of to each other in the median line. The 
danger lies in drawing down the relaxed levator vaginae so that too 
much of it will be removed. 

It is a good operation for uncicatrized lacerations through the peri- 
neal raphe that have resulted in rectocele, and prolapse of the posterior 
vaginal wall, to an extent that cannot be remedied by anything short 
of cutting off the protruding vaginal tissues. It is also an excellent 
procedure for transverse lacerations through the raphe, with or with- 
out rectocele, in which the levator vaginae, although torn loose from the 
rest of the perineum, is not relaxed. It will not then be pulled far 
enough down to be involved in the denudation, and will be reattached 
to the perineal body and vulva. 

Transverse Denudations. 

A transverse laceration at the vaginal entrance, whether superficial 
or submucous, cicatrized or not, should be closed by a transverse strip 
from half to one inch wide along the cicatrix, or by a removal of the 
whole of the relaxed tissue between the levator vaginae and constrictor 
cunni. The width of the strip is determined by the amount of pro- 
trusion between the muscles or by pressing them apart by the finger 
in the rectum. The stitches are passed antero-posteriorly. 

That such a denudation would cure any considerable misplacement 
of the parts above is scarcely to be expected, for the amount of relax- 
ation of the levator vaginae and constrictor cunni is usually such that 
a shortening of these muscles and a removal of redundant vaginal 
tissues is required. 

Star Operation. 

When such is the case a median triangular or bilateral figure may 
be drawn across the transverse strip (Figs. 139 and 140). The edges 
of the longitudinal vaginal strips are first brought together by trans- 

* Am. Journal of Obstetrics, vol. xviii., p. 173. 




206 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



verse stitches, then those of the transverse strips by stitches passed 
antero-posteriorly, and finally the vulval portions. When but little 
or no laceration of the vulval tissues exists the vulval denudation 



Fig. 139. 



Fig. 140. 




|<&» 




Star Denudations for complication of Transverse Lacerations with other varieties- 
Sutures passed. 
The interrupted lines indicate the shape of the larger labial denudation when required. 



may be reduced to a small triangle, or nick, whose apex is at the four- 
chette or posterior commissure of the labia majora ; or the labial de- 
nudation may be left out altogether. 

The following cicatrices taken from the table on pages 175 how some 
of the lacerations for which this form of denudation is applicable. 

^^SX^-H" +T ± 

As a rule the star-shaped denudations should give way to the sim- 
pler forms when the latter can be made to remove cicatricial and use- 
less tissue only, and restore the natural relation of the parts. In some 
cases the crescent denudation, or Emmet's, or Freund's bilateral can 
be made to answer. But a simpler form should never be preferred on 
purely mechanical principles, to the sacrifice of anatomical and physi- 
ological desiderata. 

Flap Operations. 

One reason of the imperfect results attained in secondary peri- 
neorrhaphy is that traction upon the edges is caused by a cutting 
away of too much superficial tissue. This may be avoided by raising 
flaps. 

The Triangular Flap Operation. 

The simplest form of flap operation is that devised by John Duncan, 
of Edinburgh * and which is practically a modified median triangular 
operation. An incision is made in the median line from the upper 
end of the laceration in the posterior vaginal wall to the posterior com- 
missure, or as far back toward the anus in the median line as the 
laceration may extend. From the lower end of this median incision, 



Hart and Barbour, Manual of Gynecology. 



bischoff's operation. 



207 



one is made on each side along the vulval border of the laceration 
to a point on the labium major as high as the denudation is to ex- 
tend. A flap is then dissected up on each side whose edges are these 
incisions. In Fig. 141 c b is the median incision, and a b the external. 
a b c forms the flap to be raised up as far as a c. The flaps are raised, 
trimmed, and stitched together in the median line by superficial 



Fig. 141. 



Fig. 142. 




Fig. 141.— Lines of Incision in the Triangular Flap Operation. (Hart and Barbour.) 
a b, labial incisions ; c 5, median line incision passing to posterior vaginal wall ; abc, flap to be 
raised. 
Fig. 142. — Flaps Raised and Sutures Passed in same Operation. (Hart and Barbour.) 

stitches, and then the labia brought together by ordinary deep cuta- 
neous sutures. Fig. 142 shows the sutures passed. Lawson Tait 
merely turns the flaps into the vagina without stitching them, and then 
passes the deep sutures under the edges of the skin so that after they 
are tied none of the threads but the knotted portions at the edge of 
the wound are visible. 



Bischoff's Operation. 

In Bischoff's operation a denudation is made similar to Freund's 
(Kuestner*) except that the tongue of vaginal tissue left in the median 
line is narrow, and the denuded strips on either side are wider and 
nearer together. Then the tongue of the posterior vaginal wall is dis- 
sected up and brought forward over the median line raphe, stitched 
between the labia and lateral walls, and the perineum united by deep 
external sutures, commencing behind. Fig. 143 represents the figure 



Zeitschrift f. Geb. und Gyn., xiii., 1. 



208 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

to be denuded ; Fig. 144 the denuded figure after the flap has been 
drawn forward. 

The operation, like Martin's, is more of an operation for prolapse 
than for restoring a normal condition of the perineum. The denuded 
figure extends far out on the labia and near the anus. 

Fig. 14?.. FlG - 14-4. 





Denudation as made by Bischoff. The Same, with Flap Raised and 

drawn forward. 

Modified Freund's Operation. 

Freund's operation is, I think, improved by cutting away only the 
cicatricial tissue, and raising a short, thick flap from the wide tongue 
of the posterior vaginal wall in the median line. The flap should 
commence at the upper end of the denuded vaginal strips on the 
median side and gradually increase in width and thickness until at the 
end it is from a quarter to a third of an inch wide. This must be 
stitched well forward toward the fourchette, and will make up for the 
previous retraction of the posterior vaginal wall. It is also well, when 
the denudation extends laterally beyond the cicatrix, to leave the 
normal membrane and raise a narrow thick flap at the sides. This 
enables us to get a firm deep hold upon the levator, and without undue 
traction upon the levator vaginae and mucous membrane, such as must 
result from a wide superficial denudation. 

The upper end may be united by superficial catgut sutures, but that 
near the hymen requires one or two deep stitches, preferably flap 
stitches, one each side. The cutaneous stitches must, of course, bring 
the tissue external to the hymen in apposition. The anterior or upper 
one should be placed well forward, and may grasp the flap of vaginal 
wall just under the mucous membrane. 

Crescentic Flap Operation. 

The crescent operation already described may, when done for a 
V-shaped laceration, be usually performed as a flap operation. The 
vaginal tongue, and if necessary the opposite edges, are dissected up 
as flaps the same as just described for converting Freund's bilateral 
operation into the flap variety. The flap is then stitched to the 
anterior curve of the crescent, either as in Fig. 136 or 138. 



UNILATERAL FLAP OPERATION. 



209 



Unilateral Flap Operation. 

The S-shaped lacerations at one side of the median line (Fig. 113) 
are usually flap lacerations, and the edge of the flap is usually 
drawn or turned in at the edge of the cicatrix. In this case a line is 
drawn along the edge of the vulval skin and mucous membrane at 
the median side of the cicatrix from the external skin as far up the 
posterior vaginal sulcus as it goes. (See Fig. 145.) The denudation 
is carried from this line laterally so as to remove the entire cicatrix. 
If the denudation is then not high enough on the side, the vaginal 
wall and vulval skin are dissected up as a narrow thick flap. Then, 
instead of removing any more tissue the vulval skin and mucous 
membrane are dissected up as a flap /, toward the opposite side as 



Fig. 145. 




Unilateral Flap Denudation. 
vvvvv, vaginal flap sutures; vl, vl, vulval superficial sutures; c c c, cutaneous deep sutures, 
passed under flap (/) after the vaginal and vulval stitches have been tied ; /, flap. The inter- 
rupted lines on either side show extent of denudation under the flap/, and the edge opposite. 



far as the laceration is known to have extended, or sufficiently, when 
the surfaces are united, to restore the size to the vaginal entrance and 
perineal body. The interrupted lines on both sides show the extent 
of denudation under the flaps. As the bottom of the laceration is 
mainly on one side, the denudation must be so. 

The edge of the flap, however, usually comes out longer than the 
other side. This is remedied by making the top of the laceration at 
the inner side of the vaginal strip and placing the stitches so as to 
draw in the flap toward the larger curves of the other side from where 
it has been prolapsed. I have noticed this same disproportion in the 
length of the sides in sewing up such lacerations after labor, and have 
remedied it in the same way, and without removing any tissue. 

At the vaginal end and in the labia, superficial catgut stitches may 
be used to unite the edges of the flap, but at the hymen and levator 
vaginas one or two deep flap stitches are of advantage. The external 

14 



210 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

stitches should, as in the modified Freund's operation, be made to 
close the parts as deep as the hymen. 

Operations upon Uncicatrized Lacerations. 

Sometimes it is possible to diagnose the character of an imcicatrized 
laceration from the appearance of the mucous membrane. But 
usually it is necessaiy to diagnose the amount of primary relaxation 
and displacement, as distinguished from the secondaiy relaxation and 
displacement in the uninjured parts. Having then calculated or as- 
certained by direct palpation just how and where the lesion occurred, 
the appropriate operation can be chosen, to restore the separated parts 
to their original relationship. 

Lacerations Involving the Sphincter Ani but not the Rectum. 

When the laceration extends into or through the sphincter ani but 
not through the cutaneous membrane lining the anal canal, the denu- 
dations are made the same as if the sphincter were not invaded. But 
greater care must be taken that the first stitch be introduced far 
enough back beside the anus to catch into the whole thickness of the 
retracted sphincter. The next stitch should be just at the external 
edge of the sphincter. Above that they are passed as in other smaller 
lacerations. 

Closure of Lacerations Extending a Short Distance into the Rectum. 

Lacerations passing through the sphincter into the anus and rectum 
need more careful attention in getting the parts about the anus in ap- 
position, but otherwise may be united very much as already described 
for the incomplete varieties. 

The denudation should include the edges of the rectal rent and the 
vaginal cicatrices, and should extend to the edges of the strip of anal 
skin lying upon the opened and straightened sphincter at the bottom of 
the field. The vaginal denudation must be extensive enough for the 
needle to reach the lacerated ends of the levator ani on one or both 
sides of the rectum. 

Hegar applies the principle of the median triangular operation. 
The figure when denuded has a butterfly shape (Fig. 146). Closure of 
the rectal rent alone would leave the figure of the shape of the modi- 
fied triangular operation for incomplete lacerations (Fig. 132). The 
rectal and vaginal stitches are placed in the deeper portions so as to close 
the upper part of the tear both in the vaginal and rectal side. This 
gives the operator an opportunity to place some of each deep and 
some superficial, according as he wishes to elevate or support the tis- 
sues. The objection to this method is that the tears are seldom median, 
and healthy .tissues are removed and cicatrices left. An equally valid 



FLAP OPERATIONS. 



211 



objection is that it does not, unless the vaginal strip be too wide, give 
a hold in the levator ani fibres beside the rectum ; and, therefore, 
although exerting great traction upon the vaginal entrance and levator 
vaginae, does not raise the pelvic floor edge or rectal promontory, and 
thus does not sufficiently protect the perineum against the reflected 
abdominal pressure. 

Freund's bilateral denudation is applicable when the bilateral vagi- 
nal laceration is found (Fig. 147). The rectum is first sewed up by 



Fig. 146. 



Fig. 147. 





ITIMS", drives 

Fig. 146.— Hegar Triangular Denudation applied to Lacerations extending into Rectum. 

v, vaginal wall ; I, labia. 

Fig. 147.— Freund's Bilateral Denudation (Kuestner) for Laceration into Rectum. 

1 1, labia ; v, vaginal wall (posterior) ; r, rectal mucous membrane ; c, vaginal denudation 
around cicatrix ; n, nick of tissue removed to render the vaginal edges more symmetrical. The 
shaded portion indicates the size and shape of the cicatricial tissue. 



stitches extending only one-third through the septum, and then the 
vaginal by stitches extending about two-thirds through * When only 
one arm of the Y extends up the vagina, a compensating small strip 
may be denuded on the sound side. (See Bilateral Operation.) 

The first external stitch should, as pointed out by T. A. Emmet, be 
introduced below and a little internal to the ends of the sphincter in 
order to get a deep hold of the fibres, and should pass obliquely to the 
edge of the anus across the strip of the anal skin into the edge of the 
muscle and out at a corresponding point opposite. As the course of 
the needle is not straight, great care must be taken to penetrate deeply 
into the muscle. The next suture is passed opposite the outer edge of 
the sphincter and catches up the external fibres. Above this they are 
passed in the ordinary way. 

Flap Operations. 

John Duncan, A. R. Simpson, Lawson Tait, and Hart and Barbour 
close these operations by a modification of the triangular flap opera- 
tion. They make a labial incision from the posterior edge of the end 



Kuestner Zeitschr. fur Geburtsh. u. Gyn., vol. xiii., No. 1. 



212 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



of the anal sphincter (Fig. 148, b) up along the outer edge of the 
laceration as in the incomplete variety. Another incision, S 1, is made 
on each side from the top or apex of the rectal opening, along the 
recto-vaginal septum to the first incision, a b, so as to pass across the 
perineal body a little in front (or above) the edges of the anal skin. 
The recto-vaginal septum is split by knife or scissors at the apex of 
the rectal opening along the line of the incision, and flaps raised both 
in front and behind it. The anterior flap, a 1 S, is raised, pared and 
attached by superficial sutures to its opposite, to constitute the poste- 
rior vaginal wall, fourchette and posterior commissure of the labia. 



Fig. 148. 



Fig. 149. 




Fig. 148.— Lines of Incision of the Triangular Flap Operation applied to Lacerations extending 
into Rectum. (Hart and Barbour.) 

a IS, flap to be raised and united to its opposite to form posterior vaginal wall ; b 2S, flap to be 
raised and united to its opposite to form anterior rectal and anal wall. 

Fig. 149.— Flaps raised and Sutures passed in same Operation. (Hart and Barbour.) 



The posterior flaps b2S are united over the rectum to constitute the 
anterior rectal and anal walls. Fig. 149 shows the flaps raised and 
united. The sides of the perineum are brought together by superficial 
and deep sutures. Tait turns the anterior flaps into the vagina and 
the posterior into the rectum without the superficial stitches. 

This method of denudation is useful, but from a strictly scientific 
standpoint is only applicable to cases of median lacerations into the 
rectum, which are the exceptional ones. 

By cutting away the cicatricial tissues from the vulva and vagina 
and then raising flaps, the largest one from the side opposite the uni- 
lateral diagonal vaginal extension, the principle of the unilateral flap 
operation (Fig. 145) can be applied (Figs. 150, 151, 152 and 153). 



FLAP OPERATIONS. 



213 



Thus the vaginal line of sutures at the recto-vaginal promontory will 
be diagonal, that of the vulva slightly diagonal while that of the rectum 
will be almost median. 



Fig. 150. 



MediarvltHe' 




Fig. 151. 



ffl.e-ill&*?; lin*. 




&]tiiv 



Fig. 150.— Unilateral Flap Operation applied to Lacerations into Rectum. Eectal superficial 
sutures (r s) passed ; vf, flap raised from posterior vaginal wall. The interrupted line shows how 
far the flap is raised. 

Fig. 151.— The Same. Rectal sutures tied, flap stitches (/s) passed. 

When the vaginal rent is bilateral two strips should be denuded and 
the tongue of vaginal tissues in the middle raised around its edges. 



Fig. 152. 
of 



Fig. 153. 





Fig. 152.— The Same. Vaginal Flap Sutures Tied. Vulval superficial sutures (ss) passed. Cuta- 
neous deep sutures (c s) passed. 
Fig. 153.— Vulval Sutures Tied. Lower cutaneous stitch (through the sphincter) tied. 



214 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



After closure of the rectum by superficial stitches it is closed the same 
as recommended for the modified Freund's operation for incomplete 
lacerations (p. 208). 

BischofTs Flap Operation has been applied with some success to 
the complete lacerations. After closure of the rectal opening the flap 
is brought forward (p. 207). 

Langenbeck*s operation, which is the oldest, is similar to the last. 
The edge of the recto-vaginal septum is denuded and then split for 
some distance. A flap is then simply cut out of the vaginal side and, 
after closure of the rectum, is stitched forwards over the new perineum 
by vaginal stitches. The external stitches are placed from before 
backward. 

Lacerations Extending High up into the Rectum. 

Lacerations deep into the rectum usually pass on one or both sides 
of the median line, as the S, V or Y-shaped, whereas in the lesser forms 
of rectal lacerations the rectal portion is rounded and may be treated 
as a median one. 

Fig. 154, 




Emmet's Method of passing the Sutures in case of a Bilateral Diagonal Laceration extending 
through the Recto- Vaginal Septum. 

In such a case it is all the more necessary that the denudation follow 
the lateral cicatrices in order not to remove the healthy tissue. 
Freund's method is the same as just described (p. 211) except that 
more rectal stitches are required. 

Emmet removes the tongue of vaginal tissue, denudes beyond both 
rectal tears on the sides, and then draws the whole together by stitches 
passed completely across and directly through the tongue of rectal 
mucous membrane (Fig. 154). 



CHOICE OF METHODS. 



215 



Tait operates upon these deep rectal lacerations by splitting the 
recto-vaginal septum (without removing any tissue) into thick flaps. 
He introduces the stitches at the vaginal edge of the raw surfaces 
parallel with the surface of the flap, carries them into the deeper 
structures and out at the rectal flap, introduces them at the rectal 
flap opposite and brings it out at the vaginal edge. In this way a 



Fig. 155. 




Splitting of the Perineum and Recto-Vaginal Septum with Flap Stitches passed, after the manner 
of Lawson Tait. Copied from Billroth and Luecke's Handbuch der Frauenkrankheiten. 

large surface is united, the deeper structures are brought together, 
the rectal edges protected by the folding flaps and the operation very 
much simplified. The results are generally conceded to be good. 
Fig. 155 represents the stitches passed. The external parts are united 
similarly. 

Choice of Methods. 

The surgeon should vary his method according to the case, and be 
guided by the amount of displacement and destruction of parts, and 
the shape and character of the cicatrix. The cicatrix should as a rule 
be excised and the denudation completed by the raising of flaps. Old 



216 LACERATION OF THE PERINEUM AND PELYIC FLOOR. 

cases may present so much shrinkage and retraction that flaps must 
be made of the cicatricial tissue. Flaps made in part of cicatricial 
tissue should generally be united by the Tait's flap stitch ; flaps of 
healthy mucous membrane by ordinary superficial stitches in the 
vulva, and deep or flap stitches in the vaginal entrance. 

Preparation of the Patient. 

For a week before an operation, in a case in which the rectal sphinc- 
ter is involved, a mild laxative should be administered every two or 
three nights, supplemented if necessary by daily enemas. A drachm 
of Comp. Tinct. Cardamom, or a grain of Piperin combined with a 
third of a grain of extract of nux vomica, may also be advantageously 
given every night for four or five nights before the operation. The 
diet throughout the week should be light and easily digestible. On 
the day before the operation the colon should be as completely 
emptied as possible by two or three copious enemas -of weak soapsuds, 
or glycerine and water in the proportion of one to ten or fifteen. If 
the contents of the colon be not brought down, the enemas should be 
given in the knee-chest rjosition. After each evacuation the genitals 
should be bathed with water, and anointed with some simple oint- 
ment, The last enema should be of plain water, and should be given 
from three to twelve hours before the operation. A little later a small 
dose of an opiate with an aromatic should be given to protect the 
rectum and anus against the seeping of watery fseces. 

When the sphincter ani 'has not been lacerated, nor the rectum 
opened at any point, all of this treatment may be dispensed with. A 
thorough evacuation of the bowels the day before, and an enema two 
or three hours before the operation will be sufficient. 

Preparations for Operating. 

The instruments necessary are a scalpel, a pair of sharp-pointed 
long-handled scissors, small and large curved needles, three tenacula, 

Fig. 156. 




Perineum Scissors 



dressing-forceps, sponge-holder, needle-holder, catgut, silkworm-gut, 
wax, heavy and fine silk, silver wire, wire-twister, sponges, three or 
four of the Langenbeck serres-fines for compressing arteries. 



OPERATIVE DETAIL. 217 

We should have an assistant for the anaesthetic, two to support the 
knees, separate the labia and. hold tenacula, and another for instru- 
ments and sponges. 

Fig. 157. 




Langenbeck Serres-fine for Compressing Arteries during the Operation. 

The patient should be placed in the dorsal position with the knees 
drawn up. The operator should be comfortably seated with a good 
light shining over his shoulders, and his instruments on a table at his 
right within easy reach. 

Operative Detail. 

Before commencing the denudation the operator should ascertain 
by palpation just what parts are out of place and relaxed, and by 
hooking the tissues together with tenacula how they can be best 
brought into place. Having then determined by inspection of the 
cicatrix and attenuated tissues what portion is to be excised and what 
to be turned up as flaps, an incision around that to be removed is 
made, and after its removal an incision along the edge of the flaps to 
be dissected up. Flaps should not extend into the muscular tissues 
unless there be cicatrized tissue or other evidence of an oblique lacera- 
tion into it, as, for instance, in the unilateral flap laceration. 

It is better to begin the denudation at the lower superficial parts 
which do not bleed as profusely nor soil the parts to be denuded 
above. Large vessels may be clamped by the serres-fines, or they 
may be tied with fine catgut, and thus time for a careful preparation 
of the surfaces be gained. 

After having performed the same operation a number of times, the 
outlining of the part to be denuded will be unnecessary, and the 
denudation can be so rapidly made, that little trouble will be experi- 
enced from the hemorrhage. Experience may often enable us to 
prepare the deeper vaginal portion first, and unite the edges before 
going any farther, as Martin recommends in his Elytrorrhaphia 
Duplex Lateralis. 

Either the knife or the scissors may be used for removing or raising 
the tissues. With the latter we can, however, work more rapidly and 
with less hemorrhage. Various special forms of knives have been 
invented, but have failed to come into general use. 

After the surface has been prepared it is well to bring the parts into 
apposition by tenacula. If they do not fit to each other they may 



218 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

then be made to do so. But the great mistake should never be made 
of trying to increase the size of the perineal body beyond the normal 
by removing healthy skin and mucous membrane, for the traction 
upon the stitches will prevent union of the superficies, and, perhaps, 
of some of the deeper essential parts. When redundant it is better 
to dissect up the skin or mucous membrane as flaps, and unite them 
by superficial stitches, for by their resulting amplitude they will add 
to the distensibility of the structures, and tend to prevent laceration 
under subsequent distension, rather than to favor it, as would be the 
case when too much is removed. 

Sutures. 

I use a semicircular needle like that described for the immediate 
perineorrhaphy, for the external stitches (p. 195). I hold the ends of 
the first two fingers within the curve, and the thumb against them 
from without, and carry the point completely around through both 
sides before drawing it through. For the vaginal and vulval stitches 

Fig. 158. Fig. 159. 





Fig. 158.— Silver Suture Bent so as to lie Flat upon the Skin. 

Fig. 159.— Silver Suture Twisted Without being properly Bent at the point of Emergence from 
the Skin, showing the harmful pressure upon the edges. The wound above the dotted lines 
usually suppurates. 

a smaller curved needle used with a needle-holder is sometimes more 
convenient. Needles mounted on a handle are not to be recommended 
as they make too large a puncture, are liable to break, require thread- 
ing after being passed, and possess no advantage over a good needle- 
holder. 

It is better to introduce the needle at or near the edge of the wound 
or flap, and pass it obliquely deep into the tissue, in order to grasp 
deeply, and at the same time take a circular direction when the sur- 
faces are coapted (see Fig. 126). The deeper the w T ound the nearer 
the edge should the needle be entered. Silver sutures (see Chapter 
IX. " Urinary Fistula,") may, however, be made to include a liberal 
portion of the skin, for when twisted they can be bent at right angles 
at the points of emergence from the skin so as to lie flat upon the 
surface. (Fig. 158 shows the silver stitches properly twisted, Fig. 159 
improperly.) 

Deep stitches should only be drawn tight enough to bring the 
surfaces together, as the subsequent inflammation will tighten them 
still more. 



THE QUILLED SUTURE. 



219 



For the rectal stitches catgut should nearly always be used. For 
the deep vaginal stitches silkworm gut or silver are preferable, that 
they may be left in place as long as desirable. For the vulva, silk- 
worm gut or silk are best, although catgut will do for vulval flaps. 
For the external stitches waxed silk or silkworm gut are the best, and 
will, if properly placed, give as good results, and much less trouble, 
than silver. Silk is usually preferable for the flap stitch, as it accom- 
modates itself better when tied to the direction of the surfaces. Silk- 
worm gut when tied draws the parts into its circle, and requires to be 
passed through the tissues in a circular direction. 

When silver sutures are used the twisted ends should be left from 
two to three inches long, and made to converge near the ends to a 
common point, and then fastened into a piece of rubber tubing. 

Fig. 160. 




Method of Securing the Twisted Ends of the Silver Sutures (Emmet). 

Catgut stitches should be left to be absorbed. Silkworm-gut may 
be left in as long as desirable, and will not ulcerate, nor be absorbed 
for a long time. Silk absorbs secretions, and may commence to 
ulcerate in from five to six days, and should be removed as soon 
as an increasing redness or commencing ulceration about the stitch is 
noticed. Silver, if properly placed, may be left for a week or more, 
but is liable to ulcerate, and require removal in five or six days when 
there is much traction upon it, or when it is twisted too tight.. 



The Quilled Suture. 

Although somewhat antiquated the quilled suture is one of the 
most useful and rational ones. It brings the deeper parts in. apposition 



220 



LACERATION OF THE PERINEUM AND PELVIC FLOOR. 



without compressing or depressing the superficial edges. It is called 
for when there has been sloughing after labor, or removal of tissue 
by previous unsuccessful operation, producing great lateral traction. 
The suture (Fig. 161) consists of a double thread passed through the 
skin about half an inch from the edge of the wound straight down 
into the deeper tissues, out over a small space at the bottom, and through 
the other side so as to emerge opposite the first point of introduction. 
Two, sometimes three, such double threads are passed and secured by 
slipping a quill or flexible bougie, or the like, into the loops of the 

Fig. 161. 




j 


9 


f 






M 


A r 


9 


f 






j 


M\ * 


I. 


; u 


• ~ 


'■• '■ ? 






Quilled Sutures, Tied (Zweifel). 



double ends on the side of introduction, and after drawing them 
tightly so as to grasp the quill, tying them over a quill on the opposite 
side. Before being tied the sutures must be drawn tight enough to 
approximate the bottom of the wound. The cutaneous edges are then 
united by several superficial stitches. 

The traction upon the quilled sutures is often very great, and in a 
few days causes some ulceration upon the skin under the quills. As 
soon as this occurs, after the fourth day, they must be taken out, 
The superficial ones should be left a little longer. Many prefer to 
secure each suture to a button plate on either side. 



INCISION OF SPHINCTER ANI — AFTER-TREATMENT. 221 

Incision of Sphincter Ani. 

As the great barrier to success in the operations for complete lacera- 
tions seems to be the traction of the sphincter ani, one or two incisions 
(open or subcutaneous) through the posterior part of the muscle are 
sometimes made over it. This effectually relieves the traction, and is 
a desirable safeguard in very old lacerations ; but is not necessary in 
lacerations of only a few months standing, provided the entire thick- 
ness of the sphincter has been coapted by the two lower external 
sutures. It is, however, sufficient in any case to cut about two-thirds 
through the muscle, and thus gain a partial relaxation. Or the in- 
ternal fibres may be relaxed by an incision half-way through the 
muscles posteriorly on one side, and the external fibres also relaxed 
by a subcutaneous incision on the other side involving only the ex- 
ternal fibres. 

After- Treatment. 

When the rectum is not involved the patient is put to bed for eight 
days, and then kept quiet for another week. A napkin should be 
pinned about the knees of restless patients so that they cannot be 
separated farther than twelve inches. The wound is kept smeared 
with- any bland ointment to protect it. A piece of lint or iodoform 
gauze may also be laid over it to absorb the discharges. 

It is well, but not absolutely necessary, to draw the urine with a 
catheter for the first two or three days, after which a flat bed-pan may 
be used. After each time that the urine is drawn or passed the nurse 
should slightly separate the upper ends of the labia, so as to barely 
expose the edges of the wound, and squeeze warm water over the vulva 
and perineum, for the purpose of removing all traces of urine and 
vaginal discharge. 

When no inclination is felt to evacuate the bowels, they need not 
be disturbed for four or five days. A dose of castor oil or a saline should 
then be given, and an evacuation secured every two days thereafter. 
The parts must, of course, be thoroughly cleansed after each passage. 
Until the bowels move the diet should be mostly liquid. 

The parts must be inspected every day or two after the third day, 
and if any odor or discharge of pus be noticed vaginal douches be 
used. One or two per cent, solutions of carbolic acid in water twice 
or three times a day according to the amount of suppuration, will be 
found very effective. If the parts are found healthy I usually order a 
douche of plain warm water twice a day after the third or fourth day, 
and direct the patient to make use of that opportunity for urinating. 

When the sphincter has been lacerated and the rectum opened the 
patient should remain longer in bed and subsist mostly on fluids for 
a week at least. Milk on account of its tendency to produce curdy 



222 LACERATION OF THE PERINEUM AND PELVIC FLOOR. 

stools should be used sparingly. Great pains should be taken to pre- 
vent a movement of the bowels for the first three or four days, for be- 
fore that, fluid fasces are liable to invade the edges of the wound and 
prevent primary union. If hard lumps come down into the rectum 
while the bowels are being moved they must be mashed against the 
sacrum by the finger introduced into the rectum. When the colon 
has previously been completely emptied, as already directed, the 
bowels may just as well be kept quiet for eight or nine days, when the 
introduction of the finger to feel for lumps will be safe. 

Undue swelling and painfulness about the perineum may excep- 
tionally require the local application of ice-bags. 

The patient should be kept in bed from ten days to three weeks 
according to the extent of the laceration. 



CHAPTER VIII. 

DISEASES OF THE BLADDEE. 

Paralysis of the Bladder. 

Paralysis of the female bladder is often an accompaniment of 
hemiplegia or paraplegia from cerebral or spinal affections, and be- 
comes a part of these more extensive affections. From my own ob- 
servation, however, I should say that in women, retention of urine in 
such cases is not so uniformly a troublesome symptom as it is in the 
paralysis of men. 

Women have paralysis of the bladder more frequently associated 
with hysteria, probably, than with cerebro-spinal disease, which con- 
dition, of course, is a part of the hysterical affection. 

Again, it may arise from reflex causes. I once saw paralysis of the 
bladder caused by the presence of a tapeworm. 

Still more frequent is the paralysis succeeding tedious, difficult, or 
instrumental labor, as the result of injury to the muscular structure 
of the bladder from long-continued direct pressure on the organ, or 
to the nerves supplying the bladder, by the use of instruments, or by 
long-continued pressure of the head. The inflammation succeeding 
labor may also affect the organ sufficiently to cause paralysis. 

Prognosis. 

Usually paralysis occurring as the result of labor is temporary, and 
amenable to judicious treatment, if it does not spontaneously subside. 
Unfortunately, however, this is not always so. I know of two in- 
stances that have resisted such management as could be devised for 
them by several able practitioners, one for twelve years and the other 
for seven years. Both of these patients use the catheter for themselves 
when there is an accumulation of urine. 

Symptoms. 

The main symptoms indicating paralysis of the bladder are inability 
to pass urine and distension of the organ. The retention is not always 
absolute ; in some instances the urine dribbles away constantly by 
drops, keeping the clothing wet. 

The patient and inexperienced friends often believe that there is 
incontinence instead of retention, on account of this continued dis- 
charge. In other cases, however, where the paralysis is more pro- 
found, there is no discharge. The distension sometimes becomes very 



224 DISEASES OF THE BLADDER. 

great, extending beyond the umbilicus half way to the ensiform car- 
tilage. 

Retention of the urine sometimes occurs as the effect of inflamma- 
tion of the urethra. This canal becomes so sensitive to the passage 
of that fluid through it, that the sphincter closes spasmodically when 
there is any attempt to urinate. 

Diagnosis. 

Paralysis of the bladder may be diagnosticated without much diffi- 
culty generally. The patient is conscious of inability to exert suffi- 
cient power to expel the urine, but often has no sensitiveness or pain 
upon voiding it. 

The hysterical form is usually attended with other symptoms of 
this affection, appears quickly and disappears as suddenly, while the 
urine is copious and clear. There is something in the manner of the 
patient which will often lead the inexperienced to think that she de- 
sires to have it drawn by the catheter. 

Cases resulting from injury at the time of labor may be traced to 
that event. 

Treatment. 

Treatment for temporary relief will consist mainly in the use of the 
catheter. I think this instrument is generally used at too long inter- 
vals, especially in the form arising from injury during labor. I have 
often known cases of this kind to be neglected for twenty-four hours 
at a time. 

As a general rule, to pass the catheter every six hours is not too 
frequent. The muscular fibres should not be stretched by a consider- 
able and prolonged distension, as that will prevent them from recover- 
ing their tone. And if the organ is kept well emptied, there is no 
danger of decomposition of the urine and the consequent irritation 
and inflammation of the mucous membrane. An intelligent nurse 
can be taught to perform catheterism very easily, and may be trusted 
to do so according to instructions as to time and other circumstances. 

If the paralysis is connected with any general condition, as hysteria, 
this latter should be attended to by general treatment. 

If the paralysis is general, the vesical affection will share in the 
general treatment of that affection. 

The general health is usually impaired even w r hen the paralysis is 
purely local in its origin, and often it is one of prostration. When 
this is the case, generous diet, exposure to, and when practicable, 
exercise in the open air, with tonics and proper alteratives, will be 
indicated. Strychnia, quinine, and iron, separately or combined, will 
be useful remedies. The strychnia is particularly indicated as giving 
tone especially to muscular fibre and hence operating favorably on 



HYPERESTHESIA OF THE BLADDER AND URETHRA. 225 

the debilitated tissue of the bladder. Phosphoric acid is also usually 
an excellent tonic in such cases. The bowels should be kept in a 
soluble condition by the gentlest of laxatives. 

When there is evidence of inflammation of any of the pelvic viscera, 
we should remove it by the proper means before resorting to direct 
remedies to remove the paralysis. After all inflammation is removed, 
we may employ electricity to stimulate the muscular fibres to contrac- 
tion. An electro-magnetic current may be passed through the bladder 
in various directions, so as to stimulate all the fibres successively, 
applying the positive pole over the spine and across the posterior part 
of the loins, iliac and sacral regions, while the negative may be brought 
in contact with the symphysis, perineum, and labia, and by means 
of a catheter introduced into the urethra, passed slowly into the 
bladder. The whole of this faradization should not last more than 
five minutes at first, and should be repeated once a day. After the 
patient has had three or four sittings, the force of the current and the 
duration may be gradually increased. It is sometimes very beneficial 
to pass the current from the anterior part of the abdomen into a 
metallic speculum in the vagina. I have seen many cases yield to 
this plan of treatment. A remedy that seems to ■ have a very ready 
effect, and to which I think I may attribute a cure in some cases, is the 
secale cornutum. The fluid extract of ergot administered in decided 
doses, once in a half hour for four or five doses, when the bladder is 
somewhat distended, often acts very promptly. A good way to admin- 
ister the ergot is to induce decided ergotism, or to give enough for that 
purpose every day and suspend the remedy in the intervals. I have 
been in the habit, also, of administering biborate of soda in doses of 
twenty grains four times a day with benefit. It is probable that all 
the substances that induce uterine contraction will influence the 
bladder similarly. 

Hemorrhage from the Bladder. 

A bloody discharge from the female bladder, not the result of organic 
lesion of that viscus, is far from infrequent. It occurs more frequently, 
judging from my own observation, about the time of the menstrual 
period and in persons whose flow is small in quantity. It is seldom, 
if ever, sufficiently copious to cause alarm, and the treatment of it may 
be trusted to the remedial measures required for the accompanying 
disease, whatever it may be. 

Hyperesthesia of the Bladder and Urethra — Irritable Bladder and Urethra. 

An irritable condition of the bladder and urethra is a very common 
occurrence among women, and is sometimes very distressing and per- 
sistent. The symptoms are frequent desire to urinate, with the dis- 
charge of but a small quantity at each time, vesical tenesmus, heat 

15 



226 DISEASES OF THE BLADDEK. 

and weight, together with a scalding sensation at the time of passing 
the water. This irritable condition may sometimes last, with varying 
severity, for weeks and even months without being attended with any 
considerable amount of apparent disease in the parts. 

Causes. 

It is many times associated with inflammation and hyperesthesia 
of the vagina, with chronic metritis in some of its various forms, 
with displacements of the uterus, and irritation of the rectum from 
hemorrhoids, fissures, etc. But sometimes we meet with it when we 
can assign no cause whatever. 

Treatment: 

When it is possible to discover and remove the cause, that, of course, 
should be done. It will often subside under the treatment for the 
vaginitis that often attends it, or that made use of to remove ulceration 
and inflammation of the cervix uteri. So, also, when displacements 
are corrected. When we cannot trace it to any of these causes, the 
urine should be examined, and if found of strong acid reaction this 
condition should be corrected. This irritable condition of the bladder 
is quite common in women advanced in age, as the result of a highly 
acid state of the urine, and may generally be relieved by the alkalies, 
of which the preparations of potassa are probably the best. The liquor 
potassse, in doses of from ten to fifteen drops, before and after eating, 
is often very efficacious. In young women of sedentary habits the 
vegetable acids will often improve the condition of the urine and 
render it less irritating. In either case the bitters may generally be 
given with advantage. There are some medicines that seem to have a 
peculiar influence upon the urinary organs, and may often be given in 
cases of this kind with great benefit. Among such are pareira brava, 
buchu, and uva ursi. The fluid extracts of these medicines are the 
most convenient forms for administration ; but sometimes the extracts 
are not good, and hence I have been in the habit of relying more on 
the decoction than any other form. I often combine the buchu and 
uva ursi with, I think, excellent effect. When the distress is consider- 
able we may very properly use belladonna suppositories, per vaginam, 
at night. A half grain of the extract in cocoa butter, the same amount 
of sulphate of morphia, will often quiet the patient and enable her to 
rest, when otherwise she would be annoyed by frequent desire to 
urinate. Vaginal injections of tepid or warm water often relieve the 
suffering, so do hip-baths and water compresses over the lower part of 
the abdomen. The daily introduction of a number 12 steel sound 
will often cure very obstinate cases. 



CHRONIC INFLAMMATION OF THE BLADDER. 227 

Chronic Inflammation of the Bladder. 

Although women are subject to acute cystitis,— probably not as often 
as men, — there is nothing in the course of the disease, or the treatment, 
that requires special consideration in a work of this kind. The chronic 
form, however, so far as I can judge from my own observation, is more 
frequent in women than in men, and its course and treatment are 
both, in some respects, quite different, so that I am induced to give it 
distinct consideration here. It often complicates the various diseases 
of the uterus and vagina, and the displacement of these organs. It is 
also caused by foreign bodies in the bladder, as calculi, and substances 
introduced from without, and by chronic cellulitis. 

Nature and Progress. 

In the beginning the inflammation in most cases is confined to the 
mucous membrane ; after awhile the muscular tissue becomes affected. 
In the early stage of the affection, while the inflammation is confined 
to the mucous membrane, the bladder empties itself completely but 
with great pain. As soon as the muscular structure is injured by the 
processes of inflammation, especially by the deposition of fibrin, the 
walls become thickened and uneven, contraction is imperfect, and 
hence the urine is retained, at first in small quantities and afterwards 
in larger ; decomposition of this fluid takes place, the inflammation is 
aggravated, and ulceration follows in many instances ; the patient some- 
times dies from protracted suffering, or life is suddenly terminated by 
the ulceration perforating the wall entirely and causing fatal inflam- 
mation in the peritoneum or cellular tissue. Occasionally the inflam- 
mation spreads to the ureters, and through them to the kidneys. The 
urethra may or may not be involved in the inflammation. Generally 
the cystic portion is more or less affected, and the ulceration in this 
direction will, in extremely rare instances, perforate the vesico- vaginal 
septum and thus cause fistula. The inflammation from foreign bodies 
contained in the bladder would be more likely to effect this condition 
than inflammation arising from any other cause. 

Symptoms. 

Dysuria, if not the most frequent symptom, is certainly one of the 
most frequent. The presence of even a small quantity of urine in 
contact with the inflamed mucous membrane irritates and causes^a 
desire to evacuate it. There is also heat, a sense of weight or drag- 
ging in the loins, the region of the bladder, and in the pelvis, with a 
great amount of general suffering ; constipation, indigestion, some- 
times nausea, and various nervous symptoms being among the general 
symptoms. 

The urgency of the symptoms will depend, in a great measure,. 



228 DISEASES OF THE BLADDER. 

upon the amount of inflammation, but somewhat also on the consti- 
tutional peculiarities of the patient. The frequency of the discharge 
becomes very great, as there is constant pain and desire to urinate on 
account of the irritating character of the urine. With the urine is 
discharged a large amount of mucus, and as the disease advances 
pus and blood-globules are found in the urinary sediment. The ap- 
pearance of the sediment is almost characteristic. It occupies the 
bottom of the vessel, is pellucid, tinged with yellow if there is pus in 
it. or red if it contains blood-corpuscles, and when poured out either 
comes in a jelly-like mass or in long strings of mucus that may be 
drawn out to great lengths. At the bottom of the sediment are usually 
found an abundance of the phosphatic salts. As the disease advances, 
the odor of the urine becomes highly ammoniacal and not unfre- 
quently fetid. Generally the odor is quite unnatural. 

Diagnosis. 

The diagnosis is not difficult. The sediment of the urine, under the 
microscope, will show the presence of pus-globules in grave cases, and 
sometimes blood-globules. "When pressed upon above the pubis the 
bladder will be found tender. This tenderness will be more evident 
upon introducing two fingers into the vagina and elevating the bladder 
upon them, while pressure is made above the pubis. The bladder 
may be thus included between the two hands. The tenacious ropy 
sediment, the pus and blood-globules, especially the former, and the 
tenderness of the bladder upon bimanual pressure are the main diag- 
nostic symptoms. 

Prognosis. 

Chronic inflammation of the bladder is an obstinate disease, and is 
very difficult of cure ; yet it probably does not often prove fatal. 

Treatment. 

The complicating conditions — as the disease is associated with 
others in the majority of instances — should be attended to with great 
diligence. The pelvic viscera are so near each other that inflammation 
seldom exists in one for a great length of time without spreading to 
others. I believe this affection is often the result of extension from 
the vagina or uterus, and in many instances it arises from pelvic peri- 
tonitis and cellulitis. Many of the remedies used for the cure of one 
of these affections will benefit the others also. The use of the hip-bath 
once or twice daily, copious warm-water injections as often, poultices, 
compresses, iodine ointment, vaginal suppositories, — of anodynes 
especially. — will all have the effect of relieving intra-pelvic hyperemia 
and hyperesthesia. Counter-irritants of a decided character may fre- 
quently be made of great service. One or two setons introduced just 



CHRONIC INFLAMMATION OF THE BLADDER. 229 

above Poupart's ligament, in one or both sides, are very effective means 
of making it. They may be controlled better than blisters or ernptive ir- 
ritants. We have a number of articles in the materia medica that exert 
a curative influence by contact with the mucous membrane of the 
bladder. They are eliminated from the blood by the kidneys, and 
held in solution or suspension in the urine, thus becoming applied to 
the diseased surface. Probably chief among these is pareira brava. I 
think the best way to administer this is in decoction, although the 
fluid extract, when properly made, is a good form; buchu, uva ursi, and 
juniper are also very useful. I think more good, in most cases, results 
from the use of buchu and uva ursi together than from either alone. 
Iodide of potassium, permanganate of potash, and some other salts of 
this alkali, the acetates and nitrates, for instance, exert an excellent 
alterative effect upon the mucous membrane of the bladder. The tere- 
binthinates may be used with great advantage in the milder forms of 
this inflammation. Perhaps balsam copaiba is the most uniformly 
beneficial of this class of remedies. Cubebs may also be employed 
occasionally with good effect. The above treatment is applicable and 

Fig. 162. 




Skene's Double Perforated Catheter 



often sufficient in the earlier stages and milder forms of chronic in- 
flammation of the bladder ; but after contraction of the organ is im- 
paired by the extension of the inflammation to the muscular structure, 
surgical treatment becomes indispensable to a successful issue. It is 
necessary that the acrid urine be completely removed from the bladder 
before it enters into chemical decomposition, which it does very quickly. 
At the same time the direct application of medicine to the inner surface 
can and ought to be made while alterative and tonic general treatment 
is instituted to overcome interstitial inflammation and remove the 
fibrinous deposit. Often we may accomplish the processes of emptying 
the bladder and applying the medicinal agents by means of the double 
catheter. To insure the efficacy of these measures the organ may be 
washed out by warm water thrown through the catheter by a David- 
son syringe, and after all the urine is washed out the medicinal solu- 
tion may be introduced, and allowed to remain until its action is 
accomplished. When there is much pain a quarter or half grain of 
morphia once in twenty -four hours will secure immunity from suffer- 
ing. We may combine with the morphia a solution of iodide of potas- 
sium, permanganate of potash, tannic acid, acetate of lead, or other 
astringent : or we administer in the same way a small amount of an 



230 DISEASES OF THE BLADDEK. 

emulsion of balsam copaiba. Nitrate of silver will also frequently 
cause a better condition of the inflamed surface. The ingenuity and 
experience of the practitioner will generally suggest remedies of the 
above character best suited to the particular case. Due caution must 
be observed not to use the remedies in too concentrated strength until 
the tolerance of the inflamed surface is ascertained. These medica- 
tions should be applied once a day at first, and afterwards as often as 
may be required. It should be borne in mind that the mucous mem- 
brane of the bladder is very sensitive and that medicines are readily 
absorbed by it. In connection with this surgical treatment ergot and 
strychnia may be given to insure tone in the muscular structure. 
They ought not to be administered, however, until the activity of the 
inflammation has somewhat subsided. Dr. J. L. Papin, of St. Louis, 
has practiced a plan for relieving the irritable and inflamed condition 
of the bladder by dilating the urethra so as to paralyze the contractile 
fibres and leave the canal patulous, thus allowing the urine to pass out 
as fast as secreted, instead of permitting it to remain in the bladder to 
irritate it. The treatment is described in a paper written by Dr. M. 
Yarnall for the January (1872) number of the Medical Archives, pub- 
lished in that city. The operation is thus described : The urethra is 
dilated " with a long pair of dressing-forceps to such an extent as to 
produce a temporary incontinence of urine, by rupturing a few of the 
fibres of the sphincter of the bladder, and repeating the operation when 
necessary, at intervals of a week or more, until the patient is completely 
relieved." Twenty cases are mentioned as having been treated in this 
way, and the report is : " In nearly every instance the relief afforded 
is almost immediate ; but in the course of a few days the irritability 
of the bladder usually returns, when the operation has to be repeated, 
and, if necessary, again repeated until a cure is accomplished." In 
one case the operation was repeated five times, in some others three 
and four times. The experience of Dr. Papin is such that he does not 
fear incontinence of urine. " The operation being at first very painful, 
it will usually be found necessary in performing it the first time to 
place the patient under the influence of an anaesthetic ; but its subse- 
quent performance being much less severe, as a rule the anaesthetic 
will not be necessary, unless the patient be of a very nervous tempera- 
ment." This dilatation will much facilitate the use of medicated in- 
jections and preclude the need of a double catheter. 

This operation is very simple, and, according to the report of Dr. 
Yarnall, very efficacious. 

I have practiced dilatation of the urethra quite frequently with re- 
sults not inferior to those here reported. 

I invariably use the finger in place of any other instrument. One of 
the dangers of dilatation of the urethra is laceration of the circular 
fibres of that canal, and consequent incontinence of urine. I have not 



STONE IN THE BLADDER. 231 

met with an instance of this kind, nor have I seen any other serious 
consequences follow dilatation. The finger may be passed through so 
slowly that the fibres will stretch, and endowed as it is with a delicate 
sense of touch, it easily recognizes the unyielding tension which indi- 
cates care. In this it would be entirely preferable to any kind of in- 
strument. Compressed sponge or laminated tents dilate so slowly and 
remain in contact with the canal so long as to induce inflammation 
and softening of the muscular fibres, and instead of preparing the way 
for further safe dilatation would predispose to laceration. 

Dr. Goodman, of Louisville, uses a catheter with a small bulb on 
the vesical extremity of it, with which he secures an empty state of the 
bladder. (Fig. 105). 

Dr. Sims's well-known practice of incising the vesico-vaginal septum 
has for its support the favorable report of its distinguished originator 
and Dr. Emmet, his successor in the Woman's Hospital of New York. 
The latter gentleman has written, and read before the Academy of 
Sciences of New York City, quite an elaborate paper advocating the 
propriety of making a fistula through which the urine will pass without 
accumulating in the bladder, and through which very effective medicinal 
application may be made to the inflamed surface. The patient may 
be placed in the position advised to operate for vesico-vaginal fistula, 
and the parts exposed by Sims's speculum. The surgeon may then 
pass a grooved director into the urethra with the groove toward the 
vaginal septum, and cut down upon the director until an opening is 
made large enough to answer the purpose. There is probably more 
danger of having the opening too small than of getting it too large, as 
the parts contract and have a strong tendency to close up before the 
cure is effected. The opening should be about an inch in length. 
With this free communication with the interior of the bladder the 
medication may be complete. Tincture of iodine, a solution of nitrate 
of. silver, and the various astringents may be applied through the arti- 
ficial opening. The injections for washing out the bladder can be used 
with such freedom as will insure cleanliness. Dr. Emmet assures us 
that this method of treatment has been almost uniformly successful in 
his hands. The operation to cure the fistulous communication be- 
tween the bladder and vagina is so well understood and so generally 
successful, that the surgeon will not dread the consequences of this 
plan as it would have been dreaded some years ago, and I need hardly 
say that the opening should not be closed until the inflammation is 
entirely cured. It often closes spontaneously. 

Stone in the Bladder. 

Vesical calculus in the female is of very rare occurrence, absolutely 
and relatively. Of all the cases of vesical calculus only about one in 
twenty is met with in the female sex. This may be accounted for by 



232 DISEASES OF THE BLADDEB. 

the size, straight form, and dilatability of the urethra, and consequent 
direct escape of small sanguineous and mucous accumulations, and 
even sandy concretions. Indeed, quite large stones are expelled 
through the urethral canal, making their way out, in some instances, 
in a few moments with acute suffering, while in others they are many 
hours in forcing a passage. It would seem that these hard substances 
are evacuated more readily during the state of pregnancy than at any 
other time ; doubtless, because of the urethra partaking in the general 
increased dilatability of the genital organs which precedes labor. 

Symptoms. 

There are probably no symptoms attendant upon stone in the blad- 
der in woman but what are produced more frequently by other causes, 
hence they are quite unreliable, and can be taken only as suspicious 
instead of diagnostic evidence of its presence. They are great and 
persistent irritability of the bladder, severe pain after voiding the urine, 
sudden cessation of the flow while there is yet a desire to urinate and 
evidently some fluid in the organ, enlargement or relaxation of the 
urethra, and incontinence of urine. The urine is also charged with 
mucus, pus, or blood, or all three of these in greater or less quantities. 
The symptoms will be more strongly marked if the calculus is rough 
and jagged in shape, and less so if the surface is smooth and even. 
All these symptoms are not present in any given case, but some of 
them are certain to be prominent and very distressing. 

Diagnosis. 

The only way to positively determine the diagnosis is by physical 
examination of the cavity of the bladder. This is done by means of 
the fingers and the sound. If two fingers be passed deeply into the 
vagina, as far as the cervix uteri, the most dependent part of the 
bladder may be pressed strongly up against the internal face of the 
pelvis, or lower portion of the anterior abdominal wall. If this latter 
be pressed well down into the pelvis with the other hand, while the 
fingers are still in the vagina, careful manipulation will scarcely fail 
to distinguish a calculus of moderate size. When the bladder is full 
of water, if the calculus is large, it may be raised, and its presence 
pretty conclusively determined by ballottement. The stone is felt, how- 
ever, more distinctly through the urethra by the sound, used the same 
as in the male. The operation may be facilitated by the fingers in the 
vagina moving the stone around. The same difficulties in making a 
perfect diagnosis are met with, as in the male, if the stone be encysted 
or adherent to the upper or anterior wall of the bladder; but if the 
instrument is sufficiently curved and moved about in various directions 
it will be detected, and its position and size ascertained with more 
precision and certainty than in the male. 



STONE IN THE BLADDER. 233 

Treatment. 

The only means of relief available is the entire removal of the 
calculus. This may be done by dilating the urethra, and extracting 
through it ; by lithotomy or lithotrity. All these operations are less 
hazardous in the female than in the male, in fact, we scarcely take the 
subject of clanger to life into consideration in operating for stone on a 
woman ; but one very great inconvenience likely to follow dilatation 
of the urethra and lithotomy is incontinence of urine, and the atten- 
tion of recent operators is turned mainly to the matter of avoiding 
this most distressing sequel. The preference is given by some surgeons 
to lithotomy, because they think this evil less frequent after it, while 
for the same reason others resort to dilatation of, and extraction 
through, the urethra. Very few now practice lithotrity in the female, 
and this operation is looked upon as attended with more hazard than 
either of the others. It is astonishing with what facility the female 
urethra may be largely and rapidly dilated. I have seen it stretched 
so as to admit the index finger in ten minutes without violence to its 
integrity. Where the stone is not very large, not over half an inch in 
diameter, we may expect to succeed by dilatation without much 
damage if proper caution and gentleness are used. When the stone is 
much larger, and especially if it is rough, we should cut. 

The operation of dilatation is simple. It may be performed by the 
finger more readily and safely as directed in chronic inflammation of 
the bladder. As soon as the finger can be made to enter the bladder 
freely, other fingers should be passed into the vagina and caused to 
press the stone forward so that its size, shape, consistence, and the 
character of the surface may be ascertained. If there is a long diameter, 
the end must be directed to the urethral opening, and retained with as 
much security as may be until the forceps are introduced and the 
stone seized. Traction should be made in the direction of the urethra 
with the instrument, while with the fingers in the vagina the efforts 
may be governed so as to keep up the right direction and steadiness, 
and also to push the stone into the urethra. Swaying the instrument 
in different directions, and performing slight rotation, the force used 
should be very gently applied and slowly increased, giving the parts 
time to stretch, and no more exerted than is just sufficient to accom- 
plish the extraction. We should not be in a hurry, but take plenty 
of time ; more damage is done by too great hurry than too great dilata- 
tion, I think. The parts are torn instead of being stretched. If the 
stone is too large to be removed in this way, we may perform 
lithotomy. 

H. Marion Sims proposed and performed lithotomy through the ves- 
ico-vaginal septum. He exposed the parts as for operation for vesico- 
vaginal fistula, introduced a curved director through the urethra, and 
cut into the bladder upon it until the opening was large enough to 



234 DISEASES OF THE BLADDER. 

permit the stone to pass. The finger was then passed through the arti- 
ficial opening by which the forceps was guided, the stone seized and 
extracted through it. The wound need not and ought not to be im- 
mediately closed, nor until the cystitis is cured, then it will generally 
spontaneously close. If not it should be treated as a fistula. 

Foreign Bodies. 

Are sometimes introduced into the bladder by accident or design. 
Lead-pencils, hair-pins, quills, etc., are found in the bladders of hys- 
terical girls. They may be generally easily extracted by dilating the 
urethra, seizing the substance with strong forceps, and withdrawing 
them. Several instances are recorded of the open-barred pessaries of 
Dr. Hodge being removed from the bladder, where they had been in- 
troduced by mistake. The practitioner, starting one limb of the 
instrument into the urethra instead of the vagina, and afterwards 
manipulating in the ordinary way, would easily pass the whole into 
the bladder without observing any difference in the passage through 
the parts. Dr. H. R. Storer, of Boston, has now had three cases of this 
kind, and others have also met with them. I have seen but one in- 
stance of the accident, or rather mistake. In that case the instrument 
was introduced by an intelligent physician, who was sick and stupefied 
by opium. As he died a few days afterward there was no opportunity 
of hearing his account of the matter. The pessary remained in the 
bladder several months, during which time the patient was married 
and became pregnant. Three months after conception the instrument 
was discovered and removed without interrupting gestation. The re- 
moval was not attended with much difficulty. The urine was all 
drawn, and as the bladder emptied and contracted the pessary, coming 
down upon the anterior wall of the vagina, was distinctly felt, and its 
shape and size easily distinguished. The little finger was first pressed 
into the urethra until it passed into the bladder, then the index, by 
which the end of one of the branches of the instrument was drawn to 
the vesical end of the urethra. The finger was then withdrawn, and 
Ricord's phimosis forceps introduced until in contact with the limb of 
the pessary. To facilitate the prehension of it by the forceps, the in- 
dex finger of the left hand in the vagina held the pessary against the 
pubis. In this way it was not at all difficult to fasten the forceps on 
the end of the limb lying in contact with the neck of the urethra, and 
extract the whole instrument. This was done by first bringing the 
point of the branch seized upon out of the meatus, depressing it toward 
the perineum until the angle at the junction with the cross-bar ap- 
peared, after which the changes were the same as removing from the 
vagina. This case was recorded by Dr. Bulkley, of Freeport, Illinois, 
in the Medical Record. Essentially the same plan enabled Dr. H. R. 



INVERSION OF THE BLADDER. 235 

Storer, of Boston, to relieve his patients. A foreign body that has been 
introduced through the urethra can, by this kind of manipulation, be 
removed through it. 

Inversion of the Bladder. 

In childhood the bladder sometimes becomes inverted and partially 
expelled through the urethra. Dr. John Croft, in " St. Bartholomew 
Hospital Reports," American Practitioner, gives the following methods 
of diagnosticating and treating inversion of the bladder : 

"A small, red, pyriform, vascular, elastic tumor, situated between the labia below the 
clitoris, and in front of the vaginal orifice; the urethra not distinguishable ; the ureters 
may be exposed, and perhaps distilling urine ; a history of more or less incontinence 
previous to the appearance of the tumor: these symptoms should lead one to recog- 
nize an inversio vesicce, and to distinguish such an affection from a solid polypoid 
growth. Mr. Holmes has described a vaginal hernia in his work on Diseases of Chil- 
dren. In that malady the urethra can be found in front of the tumor, which has not 
the red vascular appearance of an inverted vesical membrane. The best mode of 
reduction seems to be by taxis, and the thumb and fingers the best compressors. They 
should be used gently. If the child struggle much, it would be better to employ 
chloroform." 

A properly constructed compress will retain the parts in position 
until the urethra attains its normal tone. 



CHAPTER IX. 

AFFECTIONS OF THE VAGINA. 

Absence of the Vagina. 

We observe absence of the vagina when the tissues and organs in 
near relations to it are in one of two conditions : First, when, the 
rectum, bladder, and vagina are all absent and replaced by one great 
cavity, through which the urine and fseces are passed. This cavity 
is called by authors cloaca, being a common excretory canal for the 
urinary, genital, and alimentary organs. Sometimes the vagina is 
imperfectly formed, and the rectum perforates it posteriorly, while 
the urethra enters it anteriorly. Secondly, the vagina may be absent 
while the rectum and bladder are properly situated, perfect in their 
formation, and the anus and meatus urinarius both also occupying 
their normal places and performing their functions properly. In 
this last condition of the parts the vulval organs are generally all 
present ; in one case the hymen was to be seen. In by far the most 
instances there is an absence of the uterus when the vagina is not 
found, but this is not always the case. 

Causes. 
Absence of the vagina is, of course, always a congenital condition. 



In cases in which there is a common cavity for the rectum and blad- 
der, we shall have no difficulty in ascertaining it by inspecting the parts 
with the eye and passing the probe into the rectum and bladder if 
necessary. The discharges, however, will generally enable us to decide 
without this last measure. When all the adjacent organs are normal, 
we are to distinguish between occlusion by an abnormal hymen, 
rudimentary vagina, and this condition. 

Physical examination alone will enable us to do this. We shall 
not often be called upon to determine the question of diagnosis until 
there is a collection of menstrual fluid in the cavity of the uterus, or 
the patient is married. 

When there is occlusion by the hymen, with a collection of fluid in 
the vagina, the vulva will be occupied by a tumor formed of the 
pouting membrane, generally of a dark-purple color and hemispherical 
in shape, giving the sense of fluctuation when pressed upon at the 



ATRESIA VAGINJE. 237 

time the hypogastric region is percussed. When the vagina is absent, 
there will be a tumor perceptible between the bladder and rectum, 
but no protrusion between the labia. The ordinary sign so often 
mentioned of a cord-like hardness extending from the vulva upward 
is of no use, as this is obscured by the globular mass between the 
rectum and bladder. 

The treatment of absence of the vagina will be given in the treat- 
ment of atresia. 

Atresia Vaginae. 

This condition arises very much more frequently from puerperal 
inflammation of the vaginal parietes than any other cause. But any- 
thing that produces inflammation enough to destroy the epithelium 
of the mucous membrane may cause atresia, as mechanical or chemical 
agencies, scarlatina, measles, syphilis, etc. 

After extensive ulceration from these or other cases, if the denuded 
surfaces are allowed to remain in contact and at rest for a time, they 
contract adhesions, thus narrowing, or even at times completely closing, 
the cavity. In atresia occurring as the effect of inflammation every 
variety may be observed. The vagina may be closed at the vulva 
and not above, the centre may be contracted and the upper and lower 
ends be of normal dimensions, or the adhesion may take place at the 
upper part, including or not the os uteri. In all these varieties, how- 
ever, the parts not involved in the ulceration are but little affected. 
Atresia may also be a congenital defect in the organization. Con- 
genital atresia is more frequently caused by the formation of a mem- 
brane across the cavity, closing it in some part, as the hymen occa- 
sionally closes the vulva, and which is often so low down as to be 
confounded with that membrane. Such a closure, however, is usually 
farther up the cavity, sometimes near the os uteri. Partial congenital 
atresia is sometimes represented by a very narrow canal, only large 
enough to admit a probe, and which seems a very imperfect outlet for 
the menstrual discharge, and is so small as to prevent sexual inter- 
course. This form of atresia may be complete and " the organ changed 
into a solid cord," extending in part or the whole of its length. 

Diagnosis. 

Judging from my own observation we are more frequently called 
upon for a diagnosis in atresia after puberty than before. Previous 
to puberty the closure of the external opening to the vagina would 
be the only condition likely to lead to its discovery. The diagnosis 
in such cases is of little importance compared to what it becomes after 
adult age, as the defect does not interfere with the function of the 
organ. The failure in the appearance of the menses at the proper 
time in life, pain in the pelvic region, and enlargement of the abdo- 



238 AFFECTIONS OF THE VAGINA. 

men generally call for physical investigation. If it has originated in 
ulcerative inflammation, the retention of menstrual fluid, pain and 
enlargement would soon excite suspicion ; or, if the patient is married, 
the husband would be likely to discover the unusual state of things. 
Practically a very large majority of the cases we meet with will be 
attended with an accumulation of fluid. The history of the case, the 
fluctuating tumor between the bladder and rectum, felt by the finger 
in this last cavity and the catheter in the first viscus, and the presence 
of some part of the vagina in a distinguishable condition will enable 
us to decide as to the nature of the difficulty. 

Prognosis. 

There are very few cases of acquired atresia which do not admit 
of more or less complete relief. Congenital atresia with membranous 
formation across the cavity is generally curable, and when the vaginal 
cavity is so contracted as to be nearly but not entirely obliterated, 
we may hope for a cure, but when it is attended with defective de- 
velopment of the other genital organs we may expect much difficulty, 
even if a cure be practicable. 

Treatment of Atresia and Absence of the Vagina. 

The object of treatment is to overcome by surgical means the ob- 
struction to the discharges from the uterus. The vagina is a viaduct 
for the uterine discharges. This, to be sure, does not express all the 
uses of that organ, but to make it an efficient channel for the menses 
is really almost the only reason for operation in the graver varieties 
of vaginal atresia. We are not, therefore, justified in submitting our 
patient to the dangerous operation of opening up the vaginal canal 
for any other purpose. In cases, therefore, in which the uterus is 
absent we are not justified in attempting to form an artificial vagina, 
or in any way endeavoring to perfect the organs for conjugal purposes 
merely. I have known but one attempt of this kind, and in that case 
no success attended the persevering and ingenious efforts of Dr. 
Brainard. The patient was a married woman, who said she assumed 
matrimonial relations without knowing that she was not like other 
women. The vagina terminated in a cul-de-sac about an inch in 
depth. Her husband complained of her incapacity to fulfil the duties 
of a wife. They visited Dr. Brainard for surgical aid, and he had the 
kindness to allow me to witness his operations. Although the artifi- 
cial canal that resulted from his efforts was two inches in depth, it 
had a constant tendency to contract, and required the steady employ- 
ment of a glass plug to keep it open. The husband was not satisfied, 
and the law allowed him to separate from her. 

The occlusion should not be operated upon until the menstrual 



TREATMENT OF ATRESIA AND ABSENCE OF THE VAGINA. 239 

fluid fills up the uterus and distends the parts between its cavity and 
the vulva, Ordinarily, when the vagina is absent, the uterus is bound 
by areolar and fibrous tissues to its usual situation in the pelvis, and 
as distension occurs the lower portion of the organ approaches very 
near the vulva, — in two instances of absence of the vagina it was not 
more than an inch and a half from the vulva. In thus approaching 
the external organs it widely separates the bladder and rectum ; press- 
ing the former up behind the pubis, and the latter strongly into the 
hollow of the sacrum. 

This condition of things makes an operation for the opening of the 
vagina, or making an artificial canal, comparatively easy and safe. 
To attempt to reach the uterus of a girl before puberty has estab- 
lished the menses, by cutting up toward that organ from the vulva, 
is to undertake a task of very great difficulty and hazard, which, 
after the distension has brought about the changes above described, 
may be accomplished with great certainty and facility and much less 
risk. Much delay, permitting of great distension, should also be 
avoided, for Puesch tells us that in 258 cases of atresia 18 died of 
rupture of the Fallopian tube. 

The right time, then, to operate for complete atresia is as soon as 
the uterine tumor fairly fills the pelvis, and when by touch through 
the rectum with the finger, with a catheter in the urethra, we can 
assure ourselves that the uterus can be easily reached without endan- 
gering any important organ. 

Scanzoni was so impressed with the danger of wounding the bladder 
and rectum that he advised evacuating the imprisoned menstrual fluid 
by introducing a curved trocar, of large calibre, into the rectum, and 
plunging it into the most dependent part of the tumor. After the 
flow of blood has ceased, the canula should be left in the place for 
some time in order to establish a permanent opening. I think the 
danger of this operation was overestimated by Scanzoni, and cannot 
recommend the student to follow his teaching. With the precautions 
as to time and circumstances, and the proper care, the hazard is much 
less than he has estimated it. The patient may be placed in the lith- 
otomy position, a catheter introduced into the bladder and a finger 
into the rectum. The catheter will be directed strongly up behind 
the symphysis pubis, and the finger pressed firmly back against the 
sacrum. These preliminary measures being instituted, an exploring 
trocar may be passed into the central line of the vulva about half an 
inch below the urethral orifice, and pushed backward into the tumor. 
If the trocar has entered the cavity containing the menstrual fluid, 
this will begin to pass the canula upon the withdrawal of the stilet. 
When thus assured of the right direction, we may be guided by the 
trocar in making an incision that should be run along the lower side 
of it, until the opening is large enough to press the forefinger through 



240 AFFECTIONS OF THE VAGINA. 

it. With this member we may tear the opening large enough to admit 
the middle ringer with it. Through this opening the blood will soon 
be evacuated. As soon as this is the case, the cavity of the uterus and 
vagina ought to be thoroughly cleansed by tepid water thrown plen- 
tifully through a tube long enough to reach to the fundus. The arti- 
ficial opening thus made must be kept open by confining a glass plug 
large enough to keep it patulous. This plug should be worn for sev- 
eral weeks, and recourse be had to it when retraction threatens to 
obliterate the canal. 

Hewett recommends tearing through the obstructing tissue instead 
of puncturing or cutting. Others dissect through with the knife. Dr. 
T. A. Emmet advises us to use the scissors for incision into the tumor. 
And, again, a large trocar sometimes is used to penetrate the cavity 
at the point I have directed, and the finger used to enlarge the open- 
ing made by it. It happens in some cases that severe symptoms fol- 
low this operation for the sudden evacuation, such as peritonitis, 
metritis, etc. Dr. J. Marion Sims, to avoid this, evacuated the fluid 
very slowly, allowing the uterus to contract on the receding fluid as 
fast as evacuated. 

In cases where the hymen or other membrane closes the vaginal 
canal, the considerations above stated should induce us to wait until 
there is a moderate accumulation of menstrual fluid in the vagina. 
The division may then be made with scissors carried up to the mem- 
brane. The opening should be free. Not much danger of cicatrical 
contraction closing up the divided part will exist, yet for several days 
the finger should be passed above the obstruction daily to prevent any 
tendency of that kind. When the vaginal canal is contracted to very 
small dimensions, amounting to almost complete atresia, we may 
dilate this small opening by introducing rubber or metallic bougies 
graduated in size, the smaller first and larger afterwards. Sponge tents 
may be used after the dilatation has been fairly begun. Perseverance 
in the use of tents will enable us to succeed without cutting, and I 
would very much prefer it to any other method of procedure. The 
vagina may be kept open by the prolonged use of a glass plug. 

Tumors in the Vagina. 

Fibrous tumors in the vagina are occasionally met with. They are 
generally less firm, although resembling in most other respects the 
fibrous growths of the uterus, They grow in the anterior wall of the 
vagina so as to project into the bladder and vagina to about the same 
extent, or more or less in either of these cavities, according as they 
are developed nearest the membrane of the one or the other. Some- 
times they are pendulous or polypoid, hanging into the vaginal cavity 
by a neck of greater or less size. All I have seen of the intramural 



VAGINISMUS. 241 

form of these tumors were encysted, and were removed by excision. 
The cyst was opened and the tumor turned out and the wound allowed 
to close by contraction and granulation. The polypoid form may be 
removed by the ecraseur or ligature. The ecraseur is very much to 
be preferred. Fatty encysted tumors of the vagina are more rarely 
met with, and may be dissected out, in the same manner as if situated 
elsewhere. 

Cysts of various sizes containing fluid are also not infrequent. These 
may be cured by cutting out a portion of the cyst wall large enough 
to keep the incision from closing until the lining membranes 
granulate. 

Vaginismus. 

J. Marion Sims described this affection first to the Obstetrical So- 
ciety of London, December, 1861, and afterwards gave it to us in his 
Clinical Notes on Uterine Surgery. It is an " hyperesthesia of the vulva 
and hymen, attended with involuntary contraction of the sphincter 
vaginae." The parts are so very sensitive that the slightest touch with 
the finger causes great pain, and in some instances, coition is entirely 
impracticable. In all the cases I have ever examined, there was very 
decided redness and increase of the secretion of the parts exposed by 
separating the labia. Dr. Sims thought the sensitiveness confined to 
the vulva and hymen, but I apprehend that more extended observa- 
tion will establish the fact that the whole vagina is often involved. 
In one of my cases, now under treatment, the sensitiveness of the 
vulva has almost entirely disappeared ; the finger may be introduced 
into the vagina, but the upper part of this cavity is so exquisitely 
tender that the patient screams with pain as the finger approaches the 
cervix uteri. 

The general symptoms of this affection are grave according to the 
ch ronicity of the case. It generally shatters the constitutional energies 
of the patient, rendering her, according to the expression of Dr. Sims, 
a wreck. He considered it independent of inflammation. Mr. I. B. 
Brown agreed with him. It is, according to them, mere hyperesthesia. 
In my cases the parts were always in a state of inflammation ; but I 
cannot think the hyperesthesia was wholly of inflammatory origin. 
Of course I am not prepared to say that inflammation is even a general 
attendant. The observation of the profession will soon determine that 
point, as the disease is now fairly set before it, and, from the distress- 
ing symptoms, will attract much attention. My patients have appa- 
rently not been aware of their condition until married. The intensity 
of the suffering is not always sufficient to prevent coition, and some- 
times is much greater than others. The sensitiveness is greater near 
the menstrual epoch, occasionally in a very marked degree. My pa- 
tients have all been barren. 

16 



242 AFFECTIONS OF THE VAGINA. 

Diagnosis. 

The sensitiveness and contraction are characteristic, and hence 
there is no need of much labor in forming a diagnosis. The least 
touch of the mucous membrane of the vulva, with a feather, soft 
brush, or fingers, gives the patient great suffering, and sometimes 
agony unlike anything else. 

Prognosis. 

Judging from all I have seen and read upon the subject, there is 
very little, if any, tendency to spontaneous subsidence. Its duration, 
therefore, is perplexingly long. But all agree as to its curability. 

Treatment. 

The late Dr. Sims succeeded in curing all his cases by dividing the 
sphincter vaginae deeply on either side of the vaginal orifice near the 
fourchette. He made the division sufficiently deep to permit of free 
dilatation, and then kept the vagina open with large bougies until 
the wound cicatrized. The results of this operation are all that might 
be expected from it. The hyperesthesia disappears, and the obstacles 
to coition are removed, but there is necessarily great mutilation. A 
long time before Dr. Sims wrote on the subject, forcible dilatation was 
recommended to overcome the spasmodic contraction of the sphincter 
vaginae. Perhaps the best and most convenient way to dilate the 
vagina is to introduce the thumb of each hand into the vagina, with 
the palmar surface turned outward, and then forcibly separate them 
as far as possible. This will stretch the vulva, but not often rupture 
the muscular fibres to any great extent. After thus forcibly dilating, 
we should introduce the glass plug, recommended by Dr. Sims, twice 
a day, morning and evening, and allow it to remain each time from 
one to two hours. The plug ought to be from one to two inches in diam- 
eter. The introduction and presence of this hard substance at first 
gives great pain, and we may be under the necessity of using anaesthetics 
or anodynes, to enable our patient to bear it ; but after having been 
several times introduced, the parts tolerate it better, and finally we can 
use it without giving the patient any great inconvenience. The de- 
creasing sensitiveness thus manifested will be a guide to us in deciding 
when to discontinue it. Mr. I. Baker Brown, in his Surgical Diseases 
of Females, condemns Dr. Sims's operation as severe and needless, and 
gives two cases where the sensitiveness was cured by the relief of 
fissure of the rectum. He thinks the hyperaesthesia is a symptom of 
some disease of the rectum, generally fissure ; and that by incision of 
the fissures it will disappear. Dr. Braun, of Vienna, according to Mr. 
Brown, has cured one case by removing the clitoris. A case of some 
severity is reported in the London Lancet, American reprint for March, 



ACUTE VAGINITIS. 243 

1867, in the care of Dr. G. C. P. Murray, in which the hyperesthesia 
appeared to depend upon inflammation of the cervix uteri and vagina. 
It was cured by making a free application of the solid nitrate of silver 
over the inflamed cervix, and a solution to the vaginal surface. These 
applications were repeated in a fortnight, and were succeeded by the 
tincture of iodine. While there can be no doubt that Dr. Sims's plan 
is efficacious, I cannot think it necessary, and the success of other 
means by different practitioners bears me out in this opinion. We 
almost always find the patients in a state of unsatisfactory health, and, 
according to my observation, evident local disease besides that of sen- 
sitiveness ; and, from what we have learned from Mr. Brown and Dr. 
Murray, more than one kind of local disease. As in the treatment of 
all other diseases, therefore, we should carefully and diligently search 
for and cure the cause of the hyperesthesia. If it is fissure of the rec- 
tum, this should receive our first attention ; if inflammation of the 
vagina, uterus, or vulva, we ought to cure this. 

In all the cases I have seen, and I now have three under treatment, 
nothing I have tried has been of so much advantage as remedies 
directed against inflammation of the vagina and vulva. The course I 
usually pursue is to apply the solid nitrate of silver to the vulva 
every ten or fourteen days, and in the interval use glycerin and tannin. 
The first application reduces the sensitiveness very decidedly, and it 
becomes less after each successive touch, until finally cured. We 
should bear in mind that the hyperesthesia does extend into the 
vagina and to the uterus, and that it is as necessary to treat the vaginal 
cavity as the vulva. I have been in the habit, at first, of managing 
it as I would vaginitis. The strong astringents, glycerin and narcotics, 
applied by means of medicated pessaries and injections, are valuable 
adjuncts. With the local treatment, rational general treatment is 
very beneficial. Attention to the bowels, the condition of the stomach, 
and the secretions generally ; tonics, exercise, change of air, bathing, 
attention to clothing, and all the regiminal circumstances calculated 
to benefit the general condition of the patient. 

Acute Vaginitis. 

Begins generally in the lower part of the vagina, with swelling, in- 
tense redness, and dryness of the mucous surfaces of the labia, vulva 
and vagina. There is great heat in the parts, and the patient com- 
plains of burning pain in them. Difficult, painful micturition, pain 
in passing the feces, sense of weight in the pelvis, and tenesmus are 
generally present also. Not unfrequently there is backache and pain, 
radiating down the thighs, into the hips, up the spine, and into the 
head. Sometimes the symptoms are so acute as to produce general 
febrile disturbance. When this is the case, there is chilliness alternat- 



244 AFFECTIONS OF THE VAGINA. 

ing with heat, an increased frequency of the pulse, furred tongue, 
pain in the limbs, etc. In the course of thirty-six hours the pain, 
redness, and swelling spread to the whole of the vaginal cavity, and 
soon there is a profuse secretion of mucus, which, after two or three 
days, or even sooner, is mixed with pus-globules in some abundance. 
When this last is the case, the discharge is either green or yellowish in 
color, and less tenacious. This state of things lasts for from ten to 
twenty days, when the inflammation gradually subsides, becomes less 
in quantity and lighter in color, until in four or five weeks the disease 
is entirely gone, or it merges into the chronic form. The inflamma- 
tion usually involves the urethra, and sometimes the bladder, and its 
greatest intensity is almost always in the lower third of the vaginal 
canal. The inflammation sometimes spreads to the rectum. Some- 
times it attacks the mucous membrane of the cervix uteri, and even 
invades the cavities of the corpus uteri and Fallopian tubes, remain- 
ing longer in these localities than in the vaginal cavity. 

Diagnosis. 

The diagnosis of acute vaginitis is not difficult, as the parts may be 
easily seen and touched. 

Prognosis. 

As has been heretofore intimated, it subsides spontaneously, and 
leaves the parts free from disease, or in a state of chronic inflamma- 
tion. The prognosis, therefore, is favorable. 

Cause. 

It is caused by contagion more frequently, perhaps, than anything 
else, but does doubtless arise from abuses, injuries, and want of clean- 
liness, and probably other causes. I have seen the non-contagious 
form in children very much more frequently than in adults, spread- 
ing usually from the vulva upwards. Non-contagious acute vaginitis 
is not a very common affection. At first it involves the mucous mem- 
brane and submucous tissue, but before many days it is confined to 
the membrane alone. 

Treatment. 

This at first should be slightly antiphlogistic. A few grains of calo- 
mel, followed in ten or twelve hours with a saline cathartic, should be 
the first step. This may be succeeded by nauseating doses of tartar 
emetic, until the dryness and swelling have subsided. In the mean- 
time, perfect quiet in the recumbent position should be enjoined, 
the parts bathed every hour or two thoroughly with tepid water, and 
the patient should abstain from stimulating or nutritious ingesta. As 
soon as the discharge has become copious, and yellowish or green, and 



CHRONIC VAGINITIS. 245 

the swelling of the parts has entirely subsided, the treatment should 
be changed for astringents, specifics, laxatives, and baths. We may 
give half a drachm of balsam copaiba in emulsion or capsules every 
six or eight hours, and have the vagina syringed copiously with a 
saturated solution of alum, or acetate of lead, two or three times in 
twenty-four hours. Every third day a few ounces of a solution of ni- 
trate of silver, the strength of ten grains to the ounce, may be advan- 
tageously used. The bowels should be kept open, and the patient 
should abstain from stimulants at all times during the treatment. The 
astringent injection ought to be changed every five or six days, using 
alum, sugar of lead, and sulphate of zinc alternately. Perseverance 
in this treatment will very materially shorten the course of the disease. 

Chronic Vaginitis. 

This is a more frequent form of disease than the acute, and its im- 
portance will be understood from this consideration. It is in many 
instances a veiy distressing affection, and often mistaken for diseases 
of the uterus, bladder, or rectum. 

Symptoms. 

There is generally pain in the back, more frequently in the sacrum, 
and coccyx, but not seldom higher up ; pain in the groin, weight and 
sense of bearing down in the perineum, dragging in the hips and 
pelvis. A burning sensation in the vagina, extending all over the 
lower part of the person, very distressing and depressing, is sometimes 
the chief symptom complained of by the patient. In married patients 
it is the cause of distress during the act of coition, to such a degree 
sometimes as to entirely preclude such indulgence. I am now treat- 
ing a patient who assures me that although she has been married fifteen 
years, she does not remember a single instance of sexual intercourse 
that did not give her discomfort ; generally it was the cause of decided 
pain, and sometimes was entirely intolerable to her. Leucorrhcea is a 
common, but not invariable symptom ; it may be yellow or white in 
color, but when the case is not complicated with cervical inflammation 
it is always thin. In chronic vaginitis there is generally a long train 
of sjmipathetic symptoms not unlike those observed in diseases of the 
uterus. The nervous centres are disordered in their functions, pro- 
ducing nervous symptoms of almost every description. The mind is 
sometimes affected by it to irascibility, despondency, suspiciousness, 
peevishness, and purposeless instability. In other, or perhaps, the 
same cases there is palpitation of the heart and .large vessels to such a 
degree as to cause alarm for the life of the patient. Headache should 
be mentioned as quite common ; it is more commonly located in the 
occipital region, but may be in the top, forehead, temples, or all over 



246 AFFECTTOXS OF THE VAGINA. 

the head. The eyes are generally weak. The stomach is frequently 
deranged to a considerable extent, and in various ways ; and there is 
generally a constipated state of the bowels, though diarrhoea is an 
occasional symptom. There often is pain, too, in urinating, and in 
passing the faeces through the rectum. The uterus is almost always 
affected also, and through it the symptoms may become greatly diver- 
sified and increased. We should expect this complication. 

Diagnosis. 

Upon examining the vagina, the introduction of the finger will give 
some pain, sometimes a good deal, and the speculum causes a great 
amount of suffering. There is general redness of the mucous mem- 
brane; sometimes it is smooth and moist merely, or covered with a 
copious secretion of mucus ; in some instances numerous granulations 
may be seen. The granulations may be situated at the upper end of 
the vaginal cavity entirely, as I have often seen, or in the lower por- 
tion ; rarely they extend from one end of the vagina to the other. And 
again the membrane may be so raw as to bleed upon the use of instru- 
ments in making the examination. The sensitiveness, redness, and 
exaggerated secretion are conclusive and diagnostic symptoms when 
they are permanent. 



Ca 



uses. 



Chronic vaginitis is often the result of an acute attack. The inflam- 
mation only partially subsides at the time, and is continued indefinitely. 
Some of the most obstinate cases I have met with have thus resulted 
from gonorrhoea. Another set of cases are seen in patients whose hus- 
bands were the subjects of syphilis or gonorrhoea in early life, but 
who have been to all appearances cured. I am inclined to the opinion 
that chronic vaginitis is not an uncommon occurrence in women thus 
situated. It is more likely to follow recent cases of syphilis, and is some- 
times subacute in grade. Another form is apparently produced by 
abortions, colds, and other causes, with, at the same time, inflammation 
of the cervix uteri. Constipation causing sluggishness of the vaginal 
circulation, or other causes producing this vascular condition, as the 
pressure from pelvic tumors, phlegmonous effusion, etc., contribute to 
the production of chronic vaginitis. There is no doubt but that certain 
constitutional taints, as scrofula, rheumatism, and, as before intimated 
syphilis, are efficient co-operating causes. 

Prognosis. 

Chronic vaginitis, in its simpler forms, is apt to be obstinate and resist 
judicious treatment for years. It is more particularly so when origi- 
nating in constitutional diseases. When connected with incurable 
tumors it will, of course, resist all treatment. 



CHRONIC VAGINITIS. 247 

Treatment. 

The constitutional treatment of chronic vaginitis is sometimes of the 
first importance, while at other times it is unnecessary, or nearly so. 
The variety which seems to be connected with the syphilitic condition 
requires the alterative remedies which are found beneficial in this af- 
fection under other circumstances, the preparations of mercury, iodine, 
and the vegetable alteratives, for instance. When associated Avith 
scrofula the vegetable tonics, with alterative treatment, cod-liver oil, 
plenty of outdoor exercise, cold bathing, sea bathing, etc., will be appro- 
priate measures to be employed. As it is not unfrequently complicated 
with rheumatism, or this diathesis, it may be necessary to prescribe for 
it with such a consideration in mind. 

But in more simple cases, where there are no such taints or compli- 
cations, conditions exist that require a judicious course of general treat- 
ment for their removal before we can be successful in our main object. 
Such is a torpid state of the bowels and portal circle, with scanty 
secretions. Mercurial and saline laxatives, vegetable tonics, as the bit- 
ters, also alkalies, will, when judiciously used, assist us very much. 
We should be particularly careful to avoid a loaded or impacted state 
of the rectum, as this is the cause of much vaginal congestion. An in- 
jection once or twice a day, when necessary, will suffice for this. 

In all forms, in addition to the general treatment, when that is 
necessary, we shall be under the necessity of resorting to local meas- 
ures. Much benefit will be derived from a sitz-bath twice a day. The 
bath should be tepid, as a general thing, as being more likely to agree 
with the largest number of patients. When it is more agreeable, the 
bath may be cooler. It should be large enough to cover the hips, and 
the patient shouldremain in it foran hour at least, and often it is better 
to use it for a greater length of time. Of more importance are injec- 
tions. Simple water in large quantities is sometimes sufficient, but 
more frequently astringent substances will be found essential. The 
injections should be administered through a perpetual syringe, and 
the quantity should be large, say from one quart to a gallon of 
water at each time. The common astringents, as alum, sulphate of 
zinc, acetate of lead, of the strength of one drachm to the quart of 
water, will generally suffice. We find cases, however, in which none 
of these substances can be used, because they disagree with the pa- 
tient, producing dryness of the parts or increasing the inflammation. 
In such cases we must carefully search for the right local remedy. We 
may find it in tannin, tincture of the chloride of iron, astringent de- 
coctions, nitrate of silver in solution, etc. The last, used once in four 
or five days, with a glass syringe, and the other astringents between, 
often proves to be the best course. 

An excellent and very convenient mode of applying medicinal sub- 
stances to vaginal surfaces is to make small sacs of gauze or linen, and 



248 AFFECTIONS OF THE VAGINA. 

fill them with the substance intended for use, and introduce them 
into the vagina, A sac the size of a small glove finger, with a piece of 
thread attached to it, will hold an abundance of almost any remedy 
we desire to use. Tannin in powder or ointment, gall ointment, bella- 
donna ointment, and other articles are used in this way. A mixture 
I have used very commonly consists of two drops of creasote, half 
drachm of tannin, and one grain of belladonna extract, introduced at 
bedtime each night. The little bag may be removed in the morning 
by traction on the string. There are, I think, some advantages in the 
use of these little bags over the other sorts of medicated pessaries used. 
I not unfrequently inclose copaiba capsules in these little sacs, and 
think it an admirable mode of making balsamic applications to the 
vaginal mucous membrane. Where the astringents or other remedies 
are thus used they will not replace the injections wholly. Indeed, the 
vagina should be well washed out before the introduction and at the 
time of the removal of them. Patients, of course, can manage these 
applications without aid. 

Perseverance and time are important items in the treatment. If we 
can remove this chronic inflammation in three or even six months, we 
ought to be satisfied. And we ought not to be surprised to have it re- 
turn once, or more times, after it is apparently cured. It is well, also, 
to teach our patient patience in this respect. 

Puerperal Vaginitis. 

It might not seem necessary to consider the vaginitis occurring after 
labor as a separate affection, but there is so much difference — in the 
causes, nature, symptoms, and termination — between ordinary vagi- 
nitis and this form that I think it may be profitable to do so. In some 
cases of labor, circumstances occur that induce a severe form of in- 
flammation of the vagina. The one most potent is long detention of 
the fetal head in the pelvis. The pressure thus exercised upon the 
vaginal walls interupts the circulation more or less completely ; and 
if continued for a number of hours, violent reaction in the parts 
results when the pressure is removed. This pressure does not affect 
the mucous membrane of the vagina so deleteriously as the deeper seated 
tissues. The fibro-cellular part of the vaginal walls is the seat of the 
inflammation. I do not think the use of instruments, however awk- 
wa rdly, does so much damage as the long-continued pressure. It must 
not be denied, however, that instruments do give origin to this form of 
inflammation. When they do so', the inflammation is more circum- 
scribed ; it does not extend to all parts of the vagina, as is apt to be 
the case when pressure by the child's head has been the cause. On 
account of the nature of the causes, this form of vaginitis runs its 
course rapidly, and is most sure to end in structural lesions. It is in 



PUERPERAL VAGINITIS. 249 

intense forms of this sort of vaginal inflammation that sloughs and 
deep ulcerations are met with, which open the bladder and cause vesico- 
vaginal fistula, recto-vaginal fistula, and cicatrices which result in con- 
tractions and even occlusions of the vagina. It is astonishing how 
much destruction is sometimes effected by intense post-partum inflam- 
mation. I remember being called to a case, in consultation, where the 
child's head had been pressing down sufficient to bulge the perineum 
and labia for sixty hours without any movement. I delivered her with 
the short forceps in a few moments, without any violence to the parts. 
The patient was then unavoidably left in the hands of the same care- 
less practitioner that had so outrageously neglected her before the 
delivery. I saw her three months afterwards, and found the whole 
septum between the bladder and vagina gone, the urethra terminating 
abruptly, as though it had been cut straight across,in a great irregular 
cavity, that was bounded by the pubis before and the uterus behind, 
and without any defined sides to it. In still a worse case, where 
shoulder presentation had prevented the passage of the child, the 
woman was in the second stage of labor six days. The woman arose 
from her bed with a large undefinable cavity, — without any bladder, 
apparently, but the very top portion, — and the loss of two inches of 
rectum, into which the urine and faeces were poured involuntarily. In 
more than one instance I have seen the whole vagina sealed up, from 
the fourchette to the urethra, and, — as far as lean judge, — to the os 
uteri, as the effect of intense and neglected puerperal vaginitis, arising 
from unaided difficult labor. Every practitioner must meet with cases 
in which the cavity of the vagina is misshaped, and partially closed, 
from the cicatrices resulting from it. Now, much of these direful 
effects may be averted by the rational management of inflammation 
after it has been initiated. 

Symptoms. 

When injurious pressure has awakened inflammation in the vagina, 
the labia and walls become swollen, hot, and very tender. The 
patient does not generally complain of much severe pain, but there is 
a sense of soreness and heat. There is almost always fever, chilliness, 
and other evidences of disturbances of the circulation ; the tongue is 
coated, ordinarily white, sometimes yellow, or even brown, from the 
beginning. As the disease advances, two or three days from the begin- 
ning, the discharge from the vagina becomes more than ordinarily fetid, 
the labia excoriated, while the heat of the vagina is still very great, 
and there is much mucus and some pus issuing from it ; and later, 
shreds of decomposed substances, and sometimes considerable sloughs, 
are mingled with the discharge, increasing the fetor. The pulse is 
more accelerated, and sometimes becomes quite rapid ; the patient is 
much prostrated ; the tongue brown and dry, and the teeth foul with 



250 AFFECTIONS OF THE VAGINA. 

a dark clammy mucus, while the skin is bathed iu a copious perspira- 
tion. In from two to six or eight days, to these symptoms is added 
an evacuation of urine through the vagina, at first small quantities, 
and afterwards more considerable, until, in a short time, the content* 
of the bladder are passed in this way ; the parts around are excoriated 
by the urine and other acrid discharges, and a slow, uncertain con- 
valescence succeeds, with a permanent vesico-vaginal fistula. Occa- 
sionally, though not so frequently, the faeces pass through the vagina 
a few days after the beginning of the inflammation, and we have a 
recto-vaginal fistula. If neither of these evils occur, there is extensive 
ulceration, not so deep, but extending over a large surface of the 
vagina ; thus pus and acrid ichor are poured out in copious quanti- 
ties, for a long time, gradually decreasing as the surface heals. As 
these ulcerations heal up, the tissue becomes condensed and contracted, 
until such strictures or occlusions result as are above mentioned. The 
practitioner should be wide awake to this frequent course of p : st- 
partum vaginitis. 

Treatment. 

As most damage from this form of vaginitis usually accrues to the 
bladder and rectum, our first and most solicitous care should be be- 
stowed upon them. The bladder should be frequently emptied with 
the catheter ; at least every few hours the urine must be drawn ofT. 
To appreciate this direction, we have but to remember that this o:_: n 
may be considerably distended in that time, and as the septum between 
the vagina and bladder is in a state of intense inflammation, it is soft- 
ened, and therefore is easily ruptured. My impression is that fifty 
per cent, of the vesico-vaginal fistula? which now occur might be 
avoided by following this rule. Its importance cannot be overestimated. 
In very bad cases the catheter might be used even more frequently. 
or kept in the urethra. The rectum should be kept free from any 
accumulation of faeces by frequent injections of tepid water. In addi- 
tion to this prevention of fistula, the utmost cleanliness must be ob- 
served. The vagina should be washed- out with soapsuds or other 
bland detergent fluid, from four to six times a day. For the first four 
or five days the parts may be kept lubricated thoroughly by the injec- 
tion, after the water, of very bland sweet oil, or almond oil. When 
the slough begins to be thrown off, or pus and sanies become 
an injection of half a pint of tepid water, containing six or eight drops 
of creasote, twice a day. will serve to cleanse and stimulate the parts 
better than soap and water alone, which should be used between times. 
After the lapse of a week or ten days, if the ulceration is not healing, 
an injection of ten grains of nitrate of silver to the ounce of water 
may be used quite advantageously. This solution should be inj- :: : 
from a hard rubber or glass syringe, directed to the ulcerated par: I y 



URINARY FISTULA. 



251 



the finger. As the case still further advances, a solution of tannin, 
alum, sulphate of zinc, or other astringents, with the detergents, may 
be used. As the parts begin to contract by the advanced healing of 
the ulceration, the closure, partial or entire, should be anticipated by 
the introduction, daily or oftener, of wax, rubber, or other sort of 
bougies. It is well, when this last expedient is necessary, to smear 
them with ointment that may exert a healing influence on the ulcera- 
tion. The physician cannot be too attentive to these cases. He should 
see to it personally that his directions are carried out, and feel himself 
responsible for any serious permanent injury that can result from want 
of diligence. Women or their nurses cannot understand, and it is 
feared that physicians do not properly appreciate, the means of avert- 
ing the awful accidents which result from sloughing and ulceration in 
these cases. 

Urinary Fistula. 

Although generally resulting from puerperal vaginitis, fistula is 
sometimes produced by other causes. Extensive ulcerations from 
pessaries sometimes penetrate the septum between the vagina and 



Fig. 163. 



Fig. 164. 




bladder. Stone or other foreign bodies in the bladder may act as 
causes of ulcerative processes of sufficient gravity to do the same. 
Malignant diseases, as cancer of the uterus, vagina, or bladder, not 
unfrequently lay open these cavities; and, in some rare instances, 
perforations by the unskilful use of instruments have been observed. 



252 AFFECTIONS OF THE VAGINA. 

Urinary fistula may be : first, urethro- vaginal; second, vesicovaginal: 
third, vesicouterine; and, fourth, vesicouterovaginal. In the first 
variety the opening is through the urethra; in the second through the 
septum between the vagina and bladder; in the third the vesical wall 
of the cervix uteri is perforated: in the fourth, two cases of which I 
have seen, the anterior and posterior portions of the cervix are both 
laid open. The cervix is sometimes involved with the vaginal septum, 
being torn up from the extremity through the anterior lip into the 
vaginal cavity. The whole urethra sometimes sloughs off, leaving the 
pubic arch unoccupied by that canal. In one case I have recently 
seen, the urethra and neck of the bladder were lost, leaving the re- 
mainder of the vesico-vaginal septum healthy and entire. In certain 
other instances the whole lower portion of the bladder is wanting, and 
the uterus more or less mutilated. To make the condition more 
deplorable, in some rare examples of the terrible destruction of the 
parts, the rectum is involved in the common ruin. The size of the 
opening in the urethra or vesico-vaginal septum is sometimes so small 
as scarcely to be perceptible, and from this it may vary through all 
grades of dimension to the irreparable loss of tissue above described. 
The direction may be lengthwise, diagonal, tortuous, or crosswise. 

The fistula, when established, is usually associated with other effects 
of the disease from which it is produced. Cicatrices and contractions 
of the vaginal walls are very common accompaniments. These, when 
extensive, embarrass examinations and operations very much. They 
also change the size, shape, and direction of the vaginal cavity. 



The constant flow of urine through the vagina, instead of the 
urethra, is a sufficient symptom to decide the existence of fistula ; but 
we meet with cases where the flow of urine is not constant, the patient 
being able to retain for some time and then discharge her urine natu- 
rally. This circumstance is due to the plugging of a small opening 
by mucus, or the prolapse of some part of the bladder into the fistula. 
In all instances it is proper and necessary to make a clear diagnosis 
of the existence, size, shape, position, and complications of the fistula. 
This is usually easily done by the fingers and probe. The patient 
should lie on her back with her hips near the edge of the bed. and 
her legs flexed so that we may have free use of both hands. The 
fingers will readily pass through a large fistula into the bladder, and, 
by moderate care, be made to thoroughly survey it and the surround- 
ing parts. But the fistula may be so small or situated so as to entirely 
escape detection by the finger. We shall be aided in such cases by 
introducing a probe, slightly bent, through the urethra with one 
hand, while the fingers of the other are in the vagina. The bent 



URINARY FISTULA. 253 

extremity of the probe is turned toward the septum, pressed gently 
upon and passed over every part of it until it is made to pass through 
the opening, when it may be recognized by the ringer in the vagina. 
When the perforation is very small, or vesico-uterine, this kind of 
examination will fail to find it. In such cases the vagina should be 
dilated as for operation, and exposed in a good light so that every 
portion may be seen. When thus exposed, the cavity should be 
sponged out and all the urine thus removed. After this perforation, 
usually, we have but to watch a few moments when we shall perceive 
the fluid making its appearance through a minute pore, which, per- 
haps, is hidden in an ulcer in some remote part, or we may observe 
it coming through the os uteri. If, however, no urine makes its way 
through in such quantity as to indicate the place of injury, we may 
inject the bladder with tepid water in such amount as to distend the 
organ somewhat. Soon the obstacle is overcome and the water 
will escape copiously into the vagina. If it comes through the mouth 
of the uterus, the fistula is situated in the cervical cavity. This may 
be made more conclusive by plugging the os with cotton and again 
injecting the bladder. The fluid will not escape, 'of course, until the 
cotton is removed, when it will pass in such abundance as to leave no 
doubt of its place of exit. German physicians, Veit especially, recom- 
mend the use of water colored so as to make its flow through the open- 
ing more obvious. 

Prognosis. 

Having found the fistula, ascertained its size, position, shape, direc- 
tion, etc., we ought to survey the vagina, to find strictures or other 
deformity, and ascertain the distensibility of this tube. We do this 
in part to determine the prognosis of the case. Can the fistula be 
cured ? is a pertinent and important question, which will be decided 
by this kind of examination. Fortunately, now, thanks to Dr. Sims, 
almost anything short of loss of the whole septum may be cured. If 
the fistula consists of a defined opening, it matters little how large, we 
are justified in expecting success. If, as is sometimes the case, there 
are no sides, edges, or ends to it, but the vagina and bladder are one 
cavity, smooth, and continuous, we cannot reasonably undertake an 
operation unless it be to close the vulva, as has been suggested and 
practiced. Some circumstances, independent of the character and 
size of the fistula, are necessary to insure success. The vagina should 
be healthy. If the walls of this cavity are in a state of inflammation 
or congestion, the prospects of a cure are more remote. Great nervous 
susceptibility is sometimes difficult to overcome, and should be a 
reason to defer the operation. The general health of the patient is. 
also a matter of the first importance. A highly nervous condition of 
the system, with an abundance of lithates in the urine, is a condition 
in which there are many chances of failure. 



254 AFFECTIONS OF THE VAGINA. 



Treatment 



Naturally divides itself into palliative and curative. 

The palliative treatment is of great importance, and he would be a 
benefactor who should devise means of preventing the great suffering 
which results from these inevitable circumstances. The greatest 
amount of pain and suffering in such cases is caused by the flow of 
urine over the cutaneous surface. The salts held in solution by the 
urine, and the compounds resulting from their chemical decomposition 
inflame and excoriate the skin of the thighs, perineum, and external 
genital organs. Relief can be perfect only by preventing the contact 
of the urine with the skin. I think there would be little difficulty in 
making an instrument that would collect the urine, in most cases, 
before being discharged from the vagina. But the difficulty consists 
in getting one that would be tolerated in the parts. What we want is 
a sac that may be introduced and retained in the vagina with an 
opening in the upper wall opposite the fistula, large enough to permit 
the urine to flow into it. The sac should have a tube leading out of 
the vaginal orifice in order to convey the urine into a reservoir outside, 
which should be attached to the person of the patient. The sac should 
be of india-rubber or other impervious material, and so soft and smooth 
as not to irritate the mucous membrane of the vagina, and so small as 
not to distend the vagina painfully. But the urine would not flow into 
and through this tube unless the sac was distended so that the opening 
is applied to the fistula. The distension may be effected sufficiently 
after the sac is introduced, by passing cotton up through the tube. In 
order to make the urine drain through the tube something like cancel- 
larise should extend from the cotton in the sac outside through the 
tube. The drainage will be started by wetting the contained material. 
By capillary attraction the cotton absorbs the urine until it becomes 
saturated, while the loose cord will carry it off like a siphon through 
the tube. If an instrument of this kind can be made that will be 
tolerated by the vagina, I think it will act well. 

In the absence of anything to prevent the urine from flowing on the 
person, the patient must depend upon frequent ablution with warm 
water externally, and upon warm injections in the vagina. After 
washing externally, the skin should be kept covered with simple oint- 
ment. The injections should be made four or five times in the twenty- 
four hours, and the external ablutions as often as the napkins become 
sufficiently saturated to replace by others. 

Another item in the palliative management of the first importance 
is one mentioned by Dr. T. A. Emmet, viz., never to use a napkin twice 
without washing. Sometimes to avoid labor patients will simply dry 
the napkins and then use them again, thus using a napkin several 
times without washing. In this way the salts of the urine are applied 
to the skin in double strength, and the mischief greatly increased. 



URINARY FISTULA. 255 

The curative treatment consists in the closure of the fistula. 

It is hardly necessary to mention any other method than the closure 
of the fistula by suture in some form or other. Cauterization was often 
resorted to before the present safe and sure plans of operation by Drs. 
Sims and Bozeman, but is now scarcely thought of. 

To Dr. J. Marion Sims we are indebted for the cure of vesico-vaginal 
fistula ; for although others had succeeded in making cures by the use 
of nearly the same means, his ingenuity and persevering industry gave 
such positiveness and intelligent definiteness to the different steps to be 
followed in order to succeed, as to convert the operation from one of 
great uncertainty, confined to experts and experienced operators, to an 
easy, almost invariably successful one, which any surgeon of ordinary 
skill may venture upon without fear of failure. The profession is 
also indebted to Dr. T. A. Emmet, for a very lucid demonstration of 
the principles upon which the operation is founded, in his work on 
that subject. 

In describing the very simple operation of Dr. Sims one can scarcely 
do otherwise than follow, if not copy, the graphic description given by 
Dr. Emmet. Very much depends upon proper preparation of the 
system of the patient and the parts concerned, in order to insure suc- 
cessful adhesion of the two edges of the fistula. The patient should 
be in the best possible general health. I think there is great propriety 
in the distinction insisted upon by some surgeons between the plastic 
and aplastic diathesis in patients subjected to surgical operations, and 
am anxious that my patients, for some weeks before the operation, be 
subjected to the best hygienic conditions for their general health. In 
the country, if possible, plenty of exercise in the open air, good nutri- 
tious diet, a contented and happy state of mind are all that are required 
to effect the desired preparatory condition. In patients whose blood 
is impoverished from nursing, hemorrhages or other debilitating cir- 
cumstances, the ferruginous and bitter tonics should be administered. 
If the general health is well established and maintained for a little 
time, the vagina will scarcely be otherwise than firm and sound in 
texture, and free from the troublesome urinary concretions that some- 
times adhere to the mucous membrane of the vagina, the vulva, and 
even the greater labia. During the preparatory constitutional treat- 
ment, where that is necessary, the local preparation may be attended 
to — by frequent cleansing by copious injections of warm water, stimu- 
lating the parts in the vagina that are red or excoriated with a weak 
solution of nitrate of silver every four or five days. The solution may 
be of the strength of 5j to f^iv of distilled water. Dr. Emmet says 
that: 

" It is frequently necessary to pursue the same general course for many weeks before 
the parts can be brought into a perfectly healthy condition. This point is not reached 
until not only the vaginal wall, but also the hypertrophied and indurated edges of the 



256 



AFFECTIONS OF THE VAGINA. 



fistula have attained a natural color and density. This is the secret of success, but the 
necessity is rarely appreciated ; without which the most skilfully performed operation 
is almost certain to fail." 

The only other preparatory step will be the administration of a 
cathartic to evacuate 4 the bowels. The catharsis ought to be entirely 
over at least twelve hours before the operation. With these prelimi- 
naries acconrplished, we should have a large window on the sunny 



Fig. 165. 



Fig. 



Fig. 167. 




(9 



Fig. 165.— Tenaculum, with which to hold the edge of Fistula while being pared. 
Fig. 166.— Curved Scissors, for paring edge of Fistula. 
Fig. 167.— Wire Adjuster. 



side of the house, a sun-shining day, four assistants, a table of conve- 
nient height, five feet long and two wide, and the necessary instru- 
ments. The table, covered with one or two quilts, is to be placed with 
the end toward the window, from four to six feet distant. The patient 
lies on her left side, the limbs drawn up, the right a little more than the 
left with the left arm behind her, so that she rests full on the front of 
the chest. One of the four assistants uses the anaesthetic, another the 



URINARY FISTULA. 



257 



speculum, a third the sponges, and the fourth attends to the instru- 
ments. The instruments should be placed on a tray, within easy 



Fig. 168. 



Fig. 172. 




Fig. 168.— Speculum for dilating Vagina. 

Fig. 169.— Forceps for twisting the Wires. 

Fig. 170— The Catheter. 

Fig. 171.— Needle Forceps. 

Fig. 172.— Sponge-holder. The instruments are represented half size. 

reach of the operator. They are the speculum, two tenacula, scissors, 
Emmet knife, two long sponge-holders, forceps for carrying the 

17 



258 



AFFECTIONS OF THE VAGINA. 



needles, one wire adjuster, a blunt hook, forceps to twist the wire, 
half a dozen needles, slightly curved, about one inch long, armed 
with silk ligature, doubled so that the silver wire may be placed in 
the loop and thus drawn through the wound, an elastic male catheter, 
or one of Sims's S-shaped instruments, with an india-rubber tube, a 
little larger than the catheter, to carry the urine clear of the bed. 
The surgeon takes his seat at the end of the table next the window, 
near the breech of the patient, introduces the speculum, dilates the 



Fig. 173. 



Fig. 174. 





Method of paring the Edges. 



Method of passing the Needle. 



vagina, and thus brings the parts thoroughly in view, and then gives 
the instrument to the assistant to keep in that position. If the posi- 
tion of the patient prevents the parts from being thoroughly exposed 
and lighted, it should be changed until this difficulty is obviated, 
when the operator may proceed as follows: With the tenaculum in the 
left hand, the edge of the fistula is transfixed and held up to view, and, 
with the scissors, bevelled from the mucous membrane of the bladder 
outward. Dr. Emmet says the point of the tenaculum should be in- 
troduced toward the fistula, as shown in the figure. As much as prac- 



URINARY FISTULA. 



259 



ticable should be removed in this way, without changing the place of 
the tenaculum. Another place on the edge of the fistula is then seized 
and trimmed in the same manner, and so on, until the whole circle 
is denuded completely of the cicatricial tissue. We may sometimes 
succeed after a little practice in removing a complete ring of the edge 
of the fistula. This will, of course, insure to us a more perfect opera- 
tion than if the parts are removed in pieces. As this part of the 
operation is being accomplished, the assistance of the sponge will be 
required on account of the bleeding. I do not see the necessity of 
removing as much substance from the edge of the fistula as is directed 
by some authors. 

The main object, I think, is to have the edges evenly and thoroughly 
denuded of the mucous membrane. This much should be done with 



Fig. 175. 




Method of using the Tenaculum in giving aid to the Needle. 



a completeness that admits of no doubt, and if we have a good light, 
there need be no doubt, as we can see and examine the part suffi- 
ciently well to be positive. After the bleeding has ceased, we may 
insert the sutures. We commence at the angle of the wound most 
remote and difficult to reach. The needle is to be introduced first 
into the lip of the wound nearest to the operator, by starting it in 
about half an inch from the freshened edge, dipping it down, so as 
to make the point come out in the denuded portion, just at the junc- 
tion of it and' the vesical mucous membrane. The needle being 
brought through at this point, is again inserted in the opposite edge, 
corresponding as near as possible with that part whence it emerged, 



260 



AFFECTIONS OF THE VAGINA. 



and carried forward far enough to emerge half an inch beyond the 
edge of the wound, and drawn through ; the wire is then hooked in 
the double end of the silk and drawn through the wound, and de- 
tached from the silk and given to the assistant in charge of the 
speculum to retain in its place. The next suture is to correspond 
with and be placed within two lines of the first. They are thus 
placed in sufficient numbers to close the opening completely. (See Fig. 
176.) Having all the sutures introduced, the one nearest the operator 
must be isolated and twisted by the forceps made for that purpose, 

Fig. 176. 





The Fistula with Edge Pared and the Sutures Placed 



until the angle of the wound is evenly coaptated. The next is to be 
managed in the same way, and so of the remainder in order. Great 
care must be taken to see, as the closure is effected, that the lips of 
the wound are drawn evenly and smoothly together. (See Fig. 177.) 
If we are not particular, the edge of one side or the other rolls slightly 
in and unrefreshened mucous membrane is brought up to the denuded 
surface. This, I think, is a circumstance that is very liable to occur 
in the hands of an inexperienced operator. Both the insertion of the 
sutures and bringing together the edges may be facilitated by the 
skilful use of the tenaculum and the adjuster. The tenaculum will 



URINARY FISTULA. 



261 



enable us to disengage and straighten the edges, in adjusting them, 
and keep them firm in inserting the needles. The adjuster will place 
the twist of the wire in any position we may desire with reference to 
the junction of the wound. In twisting the wire there are two things 
to be avoided, — one is tightening it too much, and the other leaving it 
too lax. Experience will fix these items after a few operations, but I 
think that the operator may venture to tighten the twist of the wire 
until it fixes but does not strangulate the part included in the stitch. 
After the twist is completed, we ought to be able to pass an ordinary 
probe through the circle of the stitch without much force, and yet, 
upon its removal, there should be no apparent space. If the stitch is 
drawn too tightly, the parts will be strangulated and early cut through 

Fig. 177. 




Wire Adjuster. 

by ulceration ; if too loose, the urine will pass through as the bladder 
becomes filled and prevent adhesion. 

As each wire is adjusted and twisted it should be bent over the 
tenaculum, so as to lie flat upon the surface of the mucous membrane 
of the vagina. The operation finished, the catheter may be inserted, 
the patient placed carefully in bed, on either side, and a grain of 
opium administered. The catheter will sometimes become foul with 
deposits, and require cleaning every twelve or eighteen hours, but as 
a rule, while the urine is running freely, it may remain in place. 
Great watchfulness will alone prevent this instrument from being 
misplaced. The great desiderata of the after-treatment, are to pre- 
vent an accumulation of urine in the bladder, and the bowels from 
being evacuated. The former can be certainly accomplished in no 



262 



AFFECTIONS OF THE VAGINA, 



other way than by having a competent assistant by the patient, or 
very near her all the time, who, when the catheter does not deliver 
the water freely, will remove it and replace a clean one, however 
frequently that may be required. Dr. Emmet directs that the patient 
be placed upon her back and so remain during the after-treatment. 
He causes a double inclined plane to be made by the bedding, so that 
the legs may be bent and the head and shoulders elevated. We may 
keep the bowels quiet by administering a grain of opium twice or 
three times a day. If the patient is very restless, we ought to give as 
much more as is necessary to quiet her. The only other important 



Fig. 1 



Tig. 179. 




Closing the Wounds and Twisting the Wire Sutures. 



Removing the Sutures. 



item of treatment as a general thing is cleanliness, and for this pur- 
pose vaginal injections of tepid water, with fine toilet soap, twice 
or three times a day, will suffice. The vagina will thus be kept clean 
with much certainty. The diet should not be too sparing. The 
ordinary diet of the patient, in half or two-thirds of the quantity, I am 
convinced, is better than any considerable change in quality. The 
patient must remain quiet as practicable for nine or ten days. There 
will be no good in leaving the sutures in place longer than ten days^ 
perhaps, but there can no harm result from their longer presence. 
The removal of them is easily accomplished, by passing one blade of 
the scissors within the circle of the stitch, and dividing it, when the 
wire may be withdrawn by the forceps. The patient should keep 



URINARY FISTULA. 



263 



her position and wear the catheter for five or six days, after the 
sutures are removed, to allow the consolidation of the cicatrices and 
the closure, by contraction, of any minute opening that may have 
been left. 

Although the experience of Drs. Sims and Emmet have proven the 
propriety and efficacy of this kind of after-treatment for vesico- 
vaginal fistula, all of it is not absolutely necessary to success. In 
two instances operated on by the author, the patients were not con- 
fined to any position, and were permitted to rise from the bed and 
sit up part of the time each day, from the time of the operation until 



•Fig. 180. 




the sutures were removed. The catheter was not worn in either case, 
but it was used for the first four days, every two hours, to evacuate 
the bladder. At the end of four days, the patients were permitted 
and instructed to evacuate the bladder as often as once in two hours 
voluntarily. 

Both the patients were cured, and the comfort they enjoyed con- 
trasted very favorably with that of such as were confined to the posi- 
tion on the side or back, and were obliged to wear the catheter for ten 
or fifteen days. I have, from time to time, seen suggestions in medical 
journals, which I cannot now command, that led me to conduct the 
after-treatment in these two cases as above stated. 



264 



AFFECTIONS OF THE VAGINA. 



Simon's Method. 

In Continental Europe the late Professor Gustav Simon, greatly dis- 
tinguished himself in plastic operations. His operation for vesico- 
vaginal fistula is, in many respects, different from that above detailed. 

He places his patient on her back with the breech very much ele- 
vated. In cases where the fistula is near the orifice of the vagina, the 
limbs are placed in the position usual in lithotomy. If the fistula is 
deep, however, the limbs are brought up and extended over the sides 



Fig. 181. 




of the abdomen and breast, as shown in Fig. 180. If the uterus is suf- 
ficiently mobile, Simon draws it down to the external organs of gen- 
eration, and thus places the fistula immediately under the hand of 
the operator. In order to ascertain the mobility of the organ, he 
seizes the cervix with Museux's forceps, and draws upon it until the 
vagina is inverted, or until it is evident that the forcible traction re- 
quired will do violence to some of the tissues. When the cervix is 



URINARY FISTULA. 



265 



drawn down sufficiently, two strong threads are passed through it by 
which it is held in place. 

Fig. 181 represents this stage of procedure ; the sides of the vulva 
being held out of the way by levers made for the purpose. 

When the uterus cannot be thus drawn down, Simon uses two 
specula, and the levers in the sides of the vulva, if necessary. This 
method of exposure is very plainly illustrated by Fig. 182. One 



Fig. 182. 




large speculum draws back the perineum, and another, somewhat 
differently constructed, is placed under the symphysis pubis. 

The margin of the fistula is prepared by cutting away all the cica- 
tricial tissue, and the paring is done almost perpendicular to the sur- 
face of the vaginal mucous membrane. There is some slight inclina- 
tion or declivity in the cut edges, but they are very much less bevelled 
than in Dr. Sims's operation. Fig. 183 will give a correct idea of 
this part of the operation. A comparison with Fig. 182 will give the 



266 



AFFECTIONS OF THE VAGINA. 



reader an idea of the liberality with which Dr. Simon considers it 
necessary to pare away the tissue. 

The wound is closed with fine white silk, about the size of a large 
horsehair. Each stitch is placed a little more than a line distant 

Fig 183. 




from the one next to it. The needle is carried entirely through the 
lips of the wound, so as to penetrate the vaginal and vesical mucous 
membrane. In large fistula?, every alternate stitch is placed further 
from the edge of the wound. Fig. 184 also shows this method of in- 
troducing the stitches. The threads are carefully tied in a knot and 
the operation is completed. The closed fistula is well represented by 
Fig. 185. 



UMNAKY FISTULA. 



267 



Vesicouterine fistula? are operated upon in the same manner. 

Figs. 186 and 187 show how such fistulas are pared, the stitches in- 
troduced, and the wound closed. 

In the after-treatment, Dr. Simon thinks it superfluous, if not in- 
jurious, to leave the catheter in the bladder. He directs us to draw 
off the urine once in two or three hours, until the patient can volun- 
tarily discharge it, which she can usually do in the second or third 



Fig 18-1 




day. He allows the patient to lie in any position, and on the eighth 
or ninth day she can rise from the bed. All straining at stool, before 
the eighth or ninth day, should be avoided, if necessary, by the ad- 
ministration of opium. On the fourth or fifth day the physician 
should examine the wound with a view to the removal of the stitches, 
and if they are cutting their way through the tissues they should be 
cut and drawn out. 



268 



AFFECTIONS OF THE VAGINA. 



Of 43 fistula? in 40 women operated upon by Professor Simon, 35 
were perfectly cured, 2 of the women died, 5 more of the fistula? were 
nearly cured, and 1 was not benefited. 



KolpoMeisis. 

Cases of urinary fistula occur which cannot be cured by an opera- 
tion like the foregoing. Occasionally we meet with instances in which 
the damage is more serious, where the septum between the bladder 



Fig. 185. 




and vagina is nearly or completely destroyed, not enough of this 
structure being left to enable us to restore it. 

Surgery has successfully met these cases by closing the vaginal ori- 
fice or lower part of the vaginal canal, thus making a common 
receptacle of the posterior and lateral walls of the vagina, and the 
remaining portion of the bladder, into which the renal secretions and 
the uterine discharges are received and from which they find their way 



UEINARY FISTULA. 



269 



out through the urethral canal. The vagina may be closed by unit- 
ing the inner edges of the labia or the anterior and posterior walls 
of the vagina quite inside the orifice. The operation for uniting the 
labia will be necessitated in some instances. We occasionally meet 
with cases where the anterior wall of the vagina is entirely removed 
from the pubis, and nothing is left behind that bone to which the 
posterior wall of the vagina may be united. So complete is this 
removal of tissue that the posterior face of the pubis is covered with 
nothing but a thin cicatricial substance. The labial closure of the 
vagina is the only operation in this class of extreme cases. 



Fig. 186. 




The operation consists in removing a ring of mucous membrane from 
the inner margin of the labia, just behind the orifice of the urethra, 
three-quarters of an inch deep, and then by means of deep silver sutures 
making perfect apposition of the denuded surface. The sutures should 
be passed deep enough to include the whole of the raw portion of the 
parts, and extend on the outside three-quarters of an inch in the sub- 
stance of the labia beyond their margin. The sutures, to insure union, 
should be not more than three lines apart. The parts should be care- 
fully adjusted while the wires are being twisted, so as to make an even 
adaptation. 



270 



AFFECTIONS OF THE VAGINA. 



When there is sufficient of the vesicovaginal septum behind the 
pubis to permit its coaptation to the posterior wall, the operation per- 
formed, and proposed about the same time by Simon and Bozeman, is 
preferable to the foregoing. Simon's method is simple and effectual 
in closing the vagina thoroughly. He denominates the operation 
Kolpokleisis. The vagina is held open by the instruments and by the 
method described for operating on fistula?, and a ring of mucous mem- 
brane is removed as represented in Fig. 187 and then united by the 
sutures. Silver wire is probably the best suture for this operation. 

Fig. 187. 




Dr. Simon operates as high up in the vagina as the disease will permit, 
and, instead of confining the operation to the urethral portion of the 
cavity, he sometimes operates so near the os uteri as to preserve al- 
most the entire length of the anterior wall of the vagina. After either 
operation the treatment will consist in perfect quietude, the use of 
opium to relieve pain, and the fixed catheter to prevent an accumula- 
tion of urine until the parts are healed. 



URINARY FISTULA, 



271 



Bozeman' s Method. 

Dr. Bozeman, whose operations have attracted attention in Europe 
as well as in this country, claims to have made improvements upon the 
operation for vesico-vaginal fistula as well as in the means and methods 
of performing it. As now employed his operation has for its distinctive 
characters the button suture, the position of the patient, and a self- 
retaining speculum. The figure which is here introduced will serve 
to illustrate the position of the patient and the self-retaining speculum. 
In paring the edges of the fistula Dr. Bozeman makes the extent of 
denuded surface rather greater than is recommended in the foregoing 
pages and does not place his sutures as near together. After having pre- 
pared the parts for coaptation he passes the two ends of each suture re- 
spectively through the opening in his adjuster, as represented in figures 

Fig. 188. 




Bozeman's Apparatus for Retaining the Patient in Position. 



taken from page 24 of M. Andrade essai sur le traitement defistides vesico- 
vaginales par leprocede Americain modeae par M. Bozeman. Thus ad- 
justed the wound is ready for the button, which should be made at the 
time and in accordance with the shape and size of the wound. The 
button is cut out of a thin sheet of lead, about one line in thickness, 
long enough to project about one-fourth of an inch beyond the sutures 
at either end of the wound, and a very little more than half an inch 
wide. If the wound is straight after it is closed with the suture, the 
button should be the same ; but if the wound is curved the button 
should be made to suit the curvatures. Then with the " button-form- 
ing forceps," the groove along the centre may be formed by clamping 
across the sides from one end to the other. Thus formed, the button 
is slightly concave on the side that goes next the closed wound, and 



272 



AFFECTIONS OF THE VAGINA. 



has a groove of almost a line in depth along the centre, from one end 
to the other, and is ready to be perforated for the sutures, which, after 
measuring off the distances accurately, is done by an instrument for 
the purpose. The operator should then assure himself that all the 
spiculse caused by the perforating process are removed, and proceed 
to adjust the button. 

Fig. 189 shows the sutures through the button as it approximates 
its future site on the wound. The button is pressed down evenly 
upon the wound by means of the blunt hook, and each suture, one after 



Fig. 189. 



Fig. 190. 





the other, passed through perforated shot, and fixed by clamping the 
shot with strong forceps for the purpose. Each suture should be care- 
fully fixed in this way separately. 

In adjusting the sutures the wire should be tightened by being 
drawn through the opening at the time the shot is compressed. Only 
so much traction should be made as will bring the lips of the wound 
well up into the groove, but not strangulate them. 

The button thus applied is well represented by Fig. 190. Dr. Boze- 
man claims for this suture : 

"1. Separate and independent action of the sutures. 

"2. Perfect coaptation of the edges of the fistula, and power to hold them in a cer- 
tain relationship during the reparative process. 

"3. Perfect steadiness and support of the edges of the fistula. 

"4. Protection of the denuded edges of the fistula from the vaginal and uterine dis- 
charges, and from the urine, when there happens to be more than one opening, and it 
is not convenient or desirable to close both at the same sitting." 

We are indebted to Dr. Bozeman for a very ingenious and effectual 
method of diagnosing minute and otherwise indistinguishable fistula?. 
He calls it the linen test, and describes it as follows : 



URINARY FISTULA. 273 

" Pus and mucus in small quantities adhere to and spread upon the surface of a piece 
of linen without being absorbed by it, while water or urine, on the contrary, even in 
the minutest quantity, when brought into contact with the same material, penetrates 
almost instantly the entire thickness of the fabric. The presence of these fluids, if the 
flow is continuous, is evidenced by increasing saturation of the spot acted upon, and the 
spreading of the moisture in every direction. Thus is presented a most valuable and 
reliable means of determining the presence of urine in the vaginal or uterine canal 
when the quantity is so small as to escape observation ; not only this, but the precise 
situation of its escape from the bladder can be made with the greatest certainty when 
it would be impossible to detect it by the ordinary means, owing to the minuteness of 
the orifice or its concealment by a fold of mucous membrane. 

"In using the test nothing more is necessary than to fill the bladder with water, and 
then wipe thoroughly dry the anterior wall of the vagina. A piece of old linen is 
now rapidly spread out upon the latter, and pressed down smoothly, the patient being 
in the angular position, upon the knees. In a few moments the effect of the fluid 
upon the linen will be seen at the place of escape from the bladder, should the orifice 
be even no larger than a pin's point or a fine bristle. When the patient is placed in 
the dorsal position it is seldom necessary to inject the bladder ; the natural flow of the 
urine from the kidneys will be found quite sufficient to mark the situation of its un- 
natural escape into the vagina." 

With regard to the success of his method of operation, as now prac- 
ticed by him, he gives the following data : 

" For the period from 1867 to 1870, 17 cases, having 23 fistulse, got 24 operations, 
with the following results : 

" 21 fistulse completely closed. 

" 1 fistula completely closed in a syphilitic subject and afterwards reproduced. 

" 1 death, caused by intense heat of the weather and consequent exhaustion of the 
patient. 

" 88 per cent, of permanent cures. 

" 87J per cent, successful operations. 

"The syphilitic case was cured as regards the result of the operation, and the death 
did not result from causes connected with the operation. It will be seen, therefore, 
that the percentage of permanent cures and of successful operations is not far below 
the maximum limit. Of these 23 fistulse 3 were vesico-uterine, 1 vesico-utero-vaginal, 
1 utero-vaginal, 1 laceration of the urethra, 1 urethro-vaginal and recto.-vaginal, the 
latter admitting easily three fingers into the bowel; all of which were completely 
closed, with preservation of the functions of all the organs involved." 

In a recent letter he says, with reference to his operations : 

" By examination of my reported cases, treated by this form of suture, you will find 
the inauguration of several new procedures in the following affections: 

"1st. Urethral lacerations extending from the meatus backwards, a part or the 
whole length of the canal. By a peculiar modification of my button, the catheter in 
these cases is supported and the closure of the rent made complete to the meatus. 
(See North Am. Med.-Chir. Review, July and November, 1857.) 

" 2d. Vesico-uterine fistulse. A mode of treatment to close the fistula and preserve 
the functions of all the organs intact. The operation consists in dividing posteriorly 
the anterior lip of the cervix uteri down to the sinus, then paring the sides of the 

18 



274 ' AFFECTIONS OF THE VAGINA. 

latter and closing the wound. (See Case V., op. cit.) This was my first case, and 
here I got the idea I have since performed successfully this operation in three other 
cases. In one case the sinus opened so high up in the cervical canal that the utero- 
vesical fold of peritoneum was implicated in the operation. 

"The great value of this procedure cannot be overestimated. The procedure of 
Jobert, which consists in paring the two lips of the cervix and uniting them by suture, 
is almost universally adopted by surgeons in this class of cases. If the operation 
proves successful, the menstrual fluid is left with no other outlet than through the 
small sinus (usually no larger than the most delicate probe) into the bladder, there 
commingling with the urine and finally escaping with it through the urethra. In the 
journals I have seen the operation is claimed as a great triumph. The operation is 
frequently performed by leading surgeons. 

"With regard to this practice I unhesitatingly condemn it. It is unsurgical and 
unjustifiable, and should never be performed. 

" 3d. Vesico-utero-vaginal fistula. An original procedure for its cure. (See Case 
VIII., op. cit,, 1857.) 

' : 4th. Incarceration of the cervix uteri in the bladder. An original procedure for 
the disengagement of the cervix from its confined position and the closure of the 
fistula, with preservation of all the functions. (See Case XV., op. cit., and Cases 
XXVIIT. and XXXVIII., New Orleans Med. and Surg. Journ., January, March, and 
May, 18G0.) 

" I would add here that my cases are the only ones to be found upon record, and I 
venture the assertion, without the fear of contradiction, that no cure will ever be 
effected by any other form of suture than the button. The mechanism of this suture 
is peculiarly adapted to the successful treatment of this rare lesion." 

I am not aware that Dr. Bozeman's operation has heen objected 
to on account of want of success, for when skilfully performed all 
acknowledge its success. The chief and perhaps only objection that 
has had any effect in preventing it from general favor and practice 
is complication and consequent difficulty. This need be no objection 
if the surgeon is prepared with all the instruments now used by Dr. 
Bozeman ; with them the different steps in the operation are easily 
accomplished. He requires no assistance during the operation, a 
consideration of no small importance. 

Entero-vesical Fistula. 

Occasional instances occur in which from cancerous degeneration 
of the tissues of the bladder and intestinal canal lying in contact they 
become adherent, and afterwards perforated in such manner as to 
permit the discharge of the excretions of one organ into the other, 
thus making an entero-vesical fistula, with the urine passing into the 
intestine and out at the anus, and causing what urine passed from 
the urethra to be mixed with faeces. The author had for several 
months under his care a recto- utero- vaginal fistula. This condition 
was caused by perimetritic inflammation. The abscess perforated the 
bladder, uterus, and rectum, and the escape of faeces as well as urine 
was observed from all these cavities. The fistulous openings were 



EXTERO- VAGINAL FISTULA — RECTO- VAGINAL FISTULA. 275 

small and must have been tortuous, as these excretions escaped in 
very small quantities. The patient, a young girl, died of tubercular 
consumption after having lived in this miserable state eighteen months. 

Entero-vaginal Fistula. 

This is of two kinds, colono-vaginal and recto-vaginal. The former 
is very rare, and is caused by malignant ulceration or grave perime- 
tritis. The inflammation, when sufficiently severe to cause commu- 
nication between the vagina and colon, usually extends up into the 
abdomen and involves the viscera in that cavity to a very serious 
extent. The suppurating cavity in this case is also large, and opens 
in one place into the intestinal canal, and at another point of ulcera- 
tion into the vagina, and as the cavity of suppuration is slowly filled 
by granulations a tortuous canal is left, leading from the bowel down 
into the vaginal cavity. If the opening into the vagina can be found, 
I see no objection to closing it with the silver suture. After a long 
time these opening would probably close spontaneously, as artificial 
anus will sometimes do. 

Recto-vaginal Fistula. 

This accident does not so frequently as vesico-vaginal fistula result 
from puerperal vaginitis. Stricture of the rectum, abscess of the 
recto-vaginal septum rupturing into both cavities, and accidents with 
instruments, perhaps, as often cause it. It is not so common or fre- 
quent as vesico-vaginal fistula, nor so distressing. The passage of the 
fseces, if proper cleanliness is observed, although disgusting, is not so 
productive of inflammation and excoriation as urine, and their dis- 
charge may be controlled by appropriate fixtures. A cure is also 
more easily accomplished ; indeed, it is often spontaneous. As the 
contents of the bowels pass intermittingly, and, when in contact with 
the raw surface, do not irritate it considerably, the ulcer has time to 
contract, and healthy granulations, in a good state of the general 
health, result. 

The symptoms and diagnosis of this fistula are so obvious that I 
need not dwell upon them ; but we sometimes meet with cases where 
the opening is so small and tortuous, that great patience in the use 
of the probe w T ill be required to satisfy ourselves as to its position and 
direction. The injection of water into the rectum while the parts are 
under inspection will generally clear up all doubts. 

Treatment. 

If we are associated with these cases during the ulcerative condi- 
tion, we may conduct them to a cure with some certainty, and, per- 
haps, more readily than after the edges of the opening have cicatrized. 
The important items of treatment at such times are :. 1st,, proper atten- 



276 AFFECTIONS OF THE VAGINA. 

tion to the bowels; 2d, great cleanliness; and 3d, maintenance of 
healthy granulations until the contraction obliterates the opening. 
The bowels should be kept quiet as much of the time as possible. 
To accomplish this, the diet should be concentrated and nourishing 
in character ; beef essence, milk, eggs, crackers, coffee, or tea, and if 
necessary on account of debility, wine, or medicinal tonics ; and if 
the bowels have a tendency to move, opium in such quantities as will 
restrain them. Every four or five clays a gentle alterative, say three 
grains of blue pill, followed by a saline cathartic ; after the bowels 
have moved from this, the opium may be given to restrain them for 
four or five days again, and so on until the opening is closed. During 
this treatment there should be frequent injections of water into the 
vagina. The part should be examined with the speculum every day, 
to see that the edges remain raw. Where there is any tendency to 
cicatrize, the edges may be freely touched with pure nitric acid. If 
the cure is protracted, the acid should give place to the actual cautery. 
Toward the last, as the opening becomes small, especially if it is tor- 
tuous, a piece of twine, or what is perhaps better, a silver or iron wire, 
may be passed through it, and the ends brought out through the anus 
and vagina. If the case is chronic and the opening small, the appli- 
cation of the acid may be made every day until the edges are denuded, 
and then the same course followed as above directed. Of course, these 
applications must be made through the vagina with a speculum that 
completely exposes the part touched. If the place is large and 
chronic, we shall very much shorten the process of cure by an opera- 
tion similar to that for vesico-vaginal fistula. After having thoroughly 
evacuated the bowels, the patient may be placed in the lithotomy 
position, and exposing the parts to a strong light, the perineum may 
be retracted by the rectangular speculum blade of Sims, while the 
vulva is held open by assistants. The edges are then to be pared 
thoroughly, and the aperature closed with silver sutures. It is neces- 
sary to make a larger raw surface on the vaginal than on the rectal 
side, that the rectal edges may lie together without traction. The 
bowels will require the use of from two to four grains of opium daily 
to keep them quiet. They should not be allowed to move for ten 
days, when a saline cathartic should be given, and after it has operated 
well, the stitches removed. During the time between the operation 
and the removal of the stitches, the patient is to remain quiet in bed, 
and have injections, per vaginam, of tepid water with soap, twice a 
day. If by this operation there is imperfect closure of any part, the 
treatment recommended for recent cases will suffice to complete the 
cure. Even these larger-sized fistuUe are sometimes cured by the 
caustic acids, the actual cautery, or tinct, lyttse ; but it takes a longer 
time, and is attended with more pain and annoyance. The operation 
on these fistulae will be greatly facilitated by having the breech of the 
patient projecting somewhat over the end of the table. 



CHAPTER X. 

MENSTRUATION AND ITS DISORDERS. 

Several conditions are necessary to the healthy performance of the 
functions of menstruation. 

1st. The ovaries must be present, and sufficiently healthy to pro- 
duce ova. 

2d. The uterus must be sufficiently perfect, anatomically and physi- 
ologically, to be the medium of elimination. 

3d. A certain, but not as yet very well-defined, state of the blood 
and nervous system must exist. 

These are, probably, not all the conditions necessary to perfect 
menstruation ; but they are the obvious and undoubted ones. 

The uterus, by virtue of the conditions upon which menstruation 
depends, is naturally a hemorrhagic organ ; and it is in consequence 
of its anatomical and physiological peculiarities that the ordinary and 
frequently acting causes of uterine hemorrhage are rendered so potent 
and effective. 

The more obvious phenomena of menstruation are doubtless the 
result of a definite reflex nervous influence exerted by the ovaries 
upon the uterus. Although this influence is more distinctly mani- 
fested in the great hyperemia" which precedes the occurrence of the 
catamenial discharge, and the changes in the utricular glands and 
mucous membrane of the womb, yet it is unquestionably constant in 
its action and parallel to that which presides over the motions of the 
heart, the arteries, and the alimentary canal. Generated in the nerv- 
ous apparatus of the ovaries, and contemporaneous with the changes 
called ovulation in those organs, this influence is probably conveyed 
b}^ afferent nerves to the genito-spinal centre (the existence of which 
was first established by Budge, of Greifswalde),* or to some other 
reflecting ganglion, whence it is sent back to the uterus, giving rise 
to a wonderful series of tissue changes during the month. Some of 
these changes have been lucidly described by Dr. John Williams, in 
the Obstetrical Journal of Great Britain and Ireland, and by our own 
talented young countryman, Dr. Engelman, in his recent essay upon 
the subject, published in the American Journal of Obstetrics. These 
changes are aptly termed by Aveling, nidation and denidation. 

A few days before the menstrual flow makes its appearance, the 

* Ueber das Centrum genito-spinales des N. sympatheticus. Virchovv's Archiv f. 
Path. Anat. und Klin. Med , Band xv., S. 115-126. 



278 MENSTRUATION AND ITS DISORDERS. 

whole uterus, and especially its mucous membrane, becomes greatly 
hypertrophied and very vascular; when the discharge begins, the 
membrane is invaded by fatty degeneration. This process is so rapid 
that, in four or five days, the entire mucous membrane disappears, 
leaving the muscular structure of the inside of the uterus exposed, 
while some remnants of the utricular glands are left, and found en- 
tangled among the denuded fibres. As soon as the monthly flow 
ceases, a reproduction of the membrane is commenced, and it con- 
tinues to grow until at the end of twenty-eight days its menstrual 
maturity is attained. Accompanying these changes in the cavity of 
the uterus are others equally remarkable, affecting all the other tissues 
of the organ. The bloodvessels become enlarged, and circulate an 
increased amount of blood ; the fibrous tissue is developed beyond its 
intermenstrual condition; while hyperesthesia indicates extraordi- 
nary nervous endowment. In fact a true hypertrophy of the uterus 
occurs. During the discharge, the process of involution reduces the 
organ to its smallest dimensions, and the hemorrhage ceases. The 
culmination of this hypertrophy in the discharge of blood from the 
uterus is doubtless not merely an accompaniment, but a consequence 
of the breach of capillaries in the mucous membrane. These of course 
are physiological phenomena, but they strongly resemble pathological 
conditions, and would be so considered in any other organ in the 
human economy. Moreover, the dividing line between health and 
disease in uterine hemorrhage is as difficult to trace as that between 
sanity and lunacy.* 

Puberty. 

Puberty is the period at which the development of the human 
female renders her capable of childbearing. 

" An immense revolution takes place in the organization of the young girl. To 
her thin slender form succeeds a round and graceful contour. Her step, uncertain 
and hesitating, becomes firm and animated. The sweet and vivacious expression of 
her eyes evince the ardor with which she is endowed. Changes no legs remarkable 
take place in the system. The chest, narrow and compressed, becomes expanded and 
full. The lungs act more freely, the heart, more developed, throws the blood with 
more energy to the remotest parts of the vascular system. The areolar tissue is in- 
creased in quantity, fills up depressions and rounds out angles, making those graceful 
curves in the form that constitute female beauty. Of all the organs that feel the in- 
fluence of puberty the uterus and its appendages are the most affected by it. In girl- 
hood of small volume, at this period, the uterus, the ovaries, Fallopian tubes, and the 
breasts become greatly developed. The bones and muscles partake in the general 
development. The moral qualities of the girl are no less the subjects of change. The 
young girl, before a mere child in her tastes, inclinations, and desires, experiences a 
complete metamorphosis. Kestless and pensive, she does not know whence come the 



* The Causes and Treatment of Non-puerperal Hemorrhage of the Womb, Interna- 
tional Medical Congress, Philadelphia, September, 1876. 



PUBERTY. 279 

novel thoughts that agitate her mind; all her impressions are pleasurable; she is 
penetrated by a glowing fervor ; an unaccustomed pruriency pervades the organs of 
generation. The most important phenomenon of puberty, its indispensable acconi" 
paniment, that which transforms the young girl into a woman, the first menstrual 
flow, manifests itself." 

This is a translation of the description given by Brierre cle Boismont 
in his Treatise on Menstruation. It is a true contrast between girlhood 
and womanhood. This change is not attained in an instant, but is 
the work of years, and the development, instead of always being 
regular, steady, and equable, is in many instances quite irregular, 
unsteady, and unequal. Imperceptibly (comparing short periods) 
the lithe, muscular, bony, and angular form of the girl is lost. The 
bones of the pelvis, the lower extremities, and chest expand and grow, 
but no faster than during some other periods of girlhood ; and the 
uterus, ovaries, and Fallopian tubes assume their places and acquire 
their size gradually. At ten years, perhaps, down is observed on the 
pubis, but does not become well-grown hair until seventeen or eighteen. 
In from four to eight years usually these changes are complete. Nor 
does the form assume the becoming loveliness of a mature maiden 
immediately at the time the menses are first produced. 

The general and even the genital development is not complete for 
years after the first effusion of blood. A description which portrays 
anything but this gradual change is fanciful and misleads the student. 
The sentiments and mental habits of the girl when she first begins to 
menstruate are still childish and imperfect compared with what they 
become after the completion of her first change of life. Nor do I think 
it any more correct to say that the changes in the genital organs bring- 
about all the attributes that accompany their development; they are 
merely contemporaneous with the other and part of the whole. 

The development of the body generally, and of the sexual system 
to a perfect state, usually proceeds together, and ought to be com- 
plete at the same time and in the same degree. But these conditions 
do not always obtain. Occasionally the frame and all the organs but 
those belonging to the genital system are developed into vigorous 
womanhood, while the latter do not assume the size and energy neces- 
sary for the establishment of the sexual functions; or what is per- 
haps a more frequent condition, the individual is physically undevel- 
oped otherwise, but possesses great sexual activity if not vigor. In 
these, the general organization is feeble and imperfect, and incapable 
of meeting the requirements of womanhood, while the functions of 
menstruation and childbearing exist in perfection. The physiologist 
will have no difficulty in predicting, in instances of this kind, the in- 
fluences that will be exerted by the dominant sexual organs. He will 
see in advance the wreck that will be made of the mind, heart, lungs, 
stomach, nerves, and other organs by the overwhelming sympathies 



280 MENSTRUATION AND ITS DISORDERS. 

that must arise from the undue development of the ovaries and 
uterus. 

When this latter system is subordinate in development and func- 
tion to the system at large, then the full health and vigor of the indi- 
vidual will not be disturbed by the discharge of the sexual functions. 

The circumstances by which the girl is surrounded during the time 
when these puberal changes are going on. have a great influence upon 
the future health of the woman. This is the turning period in the life 
of the woman. She is perfected or ruined in that time. According 
to her development and surrounding circumstances will be her future 
pathological tendencies. 

The development required for efficiency and health, is strength of 
muscle and heart, and large capacity of stomach and lungs. And it 
will require but a few moments' reflection to remind the intelligent 
physiologist that the conditions by which girls at puberty are usually 
surrounded are not the best adapted to this development. The little 
girl is generally allowed to exercise in the open air in the same un- 
restrained manner that her brothers are. She exercises her muscles 
as much as her brain, and this expands her lungs and causes her heart 
to grow vigorous, and her stomach to digest well. She has no nervous 
ailments while such freedom lasts. 

She is, however, not more than ten or twelve years old before she 
is restrained in her childish sports. She is instructed that it will 
become her more to deport herself like a little lady ; which means 
that her step must be quiet, her speech less loud and energetic. She 
must appear in the street only when well dressed, and must conduct 
herself as becomes a woman. She must learn to sew and draw, which 
means that she sit still in a stooping posture : or she must go to school 
to sit and study in a close room with many others, breathing foul air 
for from four to six hours a day, and when she comes home get her 
lessons or " tasks " as they are properly called. If she has any more 
time she spends it in practicing on the piano or' receiving company 
in the parlor. In this round of confining duties the lungs are not 
expanded to their full extent for many days together ; the circulation 
is slow because there is not action enough to require quickness and 
energy in the distribution of the blood ; the muscles become weak 
and flabby from inactivity ; the nervous system is taxed by study at 
school and at home, while all the rest of the body is kept in great 
restraint. The consequences are that debility and excitability are 
predominant qualities, and the development of the lungs, heart, and 
muscles does not keep pace with the growth of the brain. If exercise 
is required, dancing or calisthenics is resorted to, because more lady- 
like than playing ball or running races in the open air. The amuse- 
ments of this period of life are not less injudicious. These children 
go to see the minstrels, go to theatres, ball-rooms, card parties, and 



PUBEKTY. 281 

other places, where they meet the opposite sex in such manner as will 
excite their emotional nature, thus encouraging early sexual develop- 
ment. About this time, between twelve and sixteen, the lungs are 
confined by corsets that fit " snugly " about the chest, preventing free 
expansion and the easy play of the diaphragm. Other effects of tight 
lacing in early as well as later life, are to press the contents of the 
abdomen down into the pelvis, and prevent a free return of venous 
blood from the lower part of the body. This downward pressure 
causes an accumulation of blood in the pelvic viscera, the rectum, 
ovaries, uterus, vagina, etc., and encourages congestions and inflam- 
mations. 

These influences, and a long train of others similar in their effects, 
are kept up from this time forward until the girl is married, and if 
she is never married always afterwards. What is usually termed 
education is commenced too early, and falls short of its objects be- 
cause it is commenced too early. Mental culture is obtained too often 
at the sacrifice of the general health, and still more frequently at an 
expense of physical development that forever mars the usefulness of 
the woman. Physical culture should be more assiduous than mental, 
during physical growth. The mind does not mature as soon as the 
body, and mental culture should be behind physical growth instead 
of before it. Six hours' study and two hours' play should be re- 
versed ; it should rather be eight hours unrestrained exercise and two 
hours' study. In writing the above I have very feebly portrayed the 
evils that usually surround girls at the time when the puberal changes 
are going forward. Let any one visit our schools for girls of this age, 
public or private, seminaries or boarding-schools, and see the require- 
ments, restraints, and confinements of the day ; let him go home with 
them and witness their want of appetite, languor, and restiveness, 
and then see the training from mothers and fathers, who, in honesty 
of affection, prevent them from going out for fear of exposure or 
improprieties, and encourage them to learn their lesson or music to 
the complete neglect of their bodies, and he will be astonished that 
as many survive the ordeal as now do. More time is necessary for 
physical development than mental, and until this truth is acted upon 
our women will become steadily less capable of bearing the hardships 
of life. 

In addition to the want of balance in the development of the 
physical organization above mentioned, the circumstances of society 
often cause premature and undue development of the sexual organs. 
Girls of different ages are congregated in large schools ; the younger 
learn from the older practices and imbibe sentiments beyond their 
age, which stimulate their passions and encourage too early and too 
vigorous sexual desires. The dress, the free and easy association of 
very young people, taught to imitate their seniors, the literature easily 



282 AMENORRHCEA. 

accessible and eagerty sought after by them, and many other circum- 
stances incident to children raised in populous cities, are calculated 
to bring out prematurely and cultivate the amorous sentiments of 
young people of both sexes. Opportunity is frequently offered to 
medical men of large experience to see lamentable suffering in young 
girls, the result of some of these causes. Some of the most intractable 
cases of uterine disease I have ever seen have occurred in girls under- 
going puberal development, traceable to undue excitement of the 
sexual organs while attending large schools or seminaries for young 
ladies. During the few years in which the girl is being developed 
into the woman, she is more susceptible to morbid influences operating 
upon the uterus and ovaries than at any other time in life, and con- 
sequently these organs should be kept as free as possible from the 
effects of all conditions which excite and stimulate them. During 
this time her education ought to be one that will keep her muscles 
occupied in the discharge of useful duties. 

This very brief summary of puberal pathology will do for a starting- 
point in the consideration of the disorders of menstruation. 

I shall consider the disorders of menstruation under four different 
divisions : 

1st. Amenorrhcea. 

2d. Menorrhagia. 

3d. Dysmenorrhcea. 

4th. Misplaced menstruation (Metatithmenia). 

Under these four heads may be included all the deviations met with 
in ordinary practice. It is usual with authors to make only three 
distinct divisions. My fourth division is spoken of by those who 
have described it as uterine hematocele, hematoma, etc. ; but I shall 
give what I consider good reasons for classing it under the general 
head of menstrual disorders. 

In the march of pathological science it will not be surprising if, 
before long, these terms are entirely dropped from the category of 
disease, and these derangements mentioned as symptoms or errors of 
function under the circumstances in which they occur. All patholo- 
gists agree that they are only symptoms, and teach students to look to 
the diseases whence they emanate as the proper objects of treatment. 
The subject is not sufficiently clear, however, to do this now, and it is 
convenient yet to employ these terms as proper heads under which to 
group the various phenomena attending them. 

AMENORRHCEA. 

Amenorrhcea means simply the absence of menstruation, and may 
appear under several different circumstances. 

1st. Menstruation may never make its appearance. 

2d. After having occurred it may cease, or, as the term is, be 



SYMPTOMS. 283 

" suppressed ;" and, again, this suppression may be suddenty brought 
about and attended with acute S3 7 mptoms, and hence properly be 
denominated acute suppression ; or it may not be attended with acute 
symptoms, and may last long enough to be called chronic. 

3d. I think it right to consider deficient menstruation as suppres- 
sion, although but partial. This partial suppression assumes two 
forms, viz., infrequency, when the intervals are uncommonly long ; and 
scantiness, the return being regular, but the quantity of the discharge 
much less than it should be. Or there may be both scantiness and 
infrequency. 

4th. The menses may be retained in the cavities of the uterus or 
vagina, or both, after having been effused. This retention is very 
different in many respects from the suppression, giving rise to quite 
a different set of symptoms, and requiring a separate sort of treat- 
ment, agreeing with it only in the non-appearance of the blood ex- 
ternally. 

Pathology and Morbid Anatomy. 

The pathological states upon which the symptom amenorrhoea is 
based are very numerous, and sometimes inscrutable. The more 
obvious are the following : Congenital absence of the uterus or ovaries, 
or both ; congenital or acquired atrophy of these organs ; acute or 
chronic disease of the uterus aud ovaries. The general conditions 
causing it are ansemia, cachexia, pregnancy, and nursing, serious dis- 
eases of any of the vital organs or nervous system, and occlusion of 
some part of the genital passage. 

Symptoms. 

The local symptoms which attend the absence of the menses will 
differ according to the conditions which give rise to it. In acute 
suppression we shall have signs of great congestion, or inflammation 
of the uterus. The patient, after commencing to menstruate, being 
subjected to the causes necessary to suppression, such as the partial 
or general application of cold, is seized with pain in the back, hypo- 
gastric region, and hips, attended with a sense of chilliness more or 
less intense. These symptoms are usually succeeded by febrile reac- 
tion, headache, pain in the limbs, general languor, white tongue, and 
a persistent pain of varied severity in the region of the uterus. There 
is, in this state of things, as there seems to be, inflammation of the 
uterus and ovaries. The symptoms may subside, and generally do 
in a very few days, leaving more or less local discomfort in the j)eivis 
and neighborhood. At the next menstrual period, if the uterus is 
not much diseased, and the system not greatly deranged, the blood is 
effused, but seldom with the same naturalness in quantity, quality, 
and painlessness as before ; there is often more or less pain, which is 
manifested henceforth at each successive period. 



284 AMENORRHEA. 

At other times the discharge fails to show itself after having been 
thus suppressed, and the case becomes chronic, lasting an uncertain 
length of time. When this is the case, the non-appearance is likely 
to be attended by chronic inflammation of the uterus and ovaries, as 
the result of the acute attack, and the morbid effects brought about 
by uterine sympathies derange the stomach, bowels, liver, in fact all 
the chylopoetic organs, to such a degree as to render chymiflcation 
or chylification imperfect. Sanguification will be thus vitiated, anaemia 
or cachexia results, and the patient becomes broken down and " mis- 
erable." We cannot but see in this catenation of circumstances the 
complicated effects resulting from inflammation of the uterus. 

Should the suppression be primary, — by this I mean to say, should 
the menses never have made their appearance, — the girl, if old enough 
and sufficiently developed, will suffer differently. And there is very 
nearly, if not quite, the same set of symptoms present in cases where 
they have made their appearance imperfectly in quantity and quality, 
or for a few times, and then ceased. The patient suffers under the 
symptoms of imperfect sanguification : inability to exercise, palpita- 
tion of the heart, shortness of breath, torpid liver and bowels, want 
of appetite, or an appetite for improper food at improper times, de- 
spondency, great apathy, and timidity. The surface is pale, and 
either white and translucent, or more commonly of a greenish hue. 
The sufferings are often very great and protracted, and not unfre- 
quently merge into those of tuberculosis, insanity, or other serious 
organic diseases. It is not unusual, even in cases where menstruation 
has never been perfectly established, to find the patient afflicted, also, 
with symptoms of inflammation of the uterus. 

The general symptoms accompanying scanty menstruation, when 
the scantiness is the result of imperfect establishment, are very much 
of the above character, viz., those connected with anaemia, etc. But 
the scantiness and infrequency, as also the entire suppression of men- 
struation, usually depend upon organic changes in the uterus grad 
ually brought about by chronic inflammation. What these are we 
cannot always determine. Sometimes, however, we find the fibrous 
structure condensed until the bulk of the organ is smaller and harder 
than natural; at other times it is greatly enlarged, as I have verified 
by examination. The most common alteration is condensation and 
atrophy. In such instances there will, of couse, be quite a different 
set of symptoms, in fact many if not all thesymptoms found described 
in connection with chronic inflammation of the substance of the cervix 
and body of the uterus. I need not enumerate them here, but refer 
the reader to the article in which the general symptoms of these con- 
ditions are given. Chronic amenorrhcea, or scanty or infrequent men- 
struation, is in this way associated with the most miserable states of 
general health. 



SYMPTOMS. 285 

We are not to believe, however, that the absence of the menses is 
the cause of such nervous suffering as we often see associated with it, 
but that it is caused by the condition of the uterus and other organs 
upon which the irregularity depends. The non-appearance of the 
menses on account of the absence of the uterus is not usually attended 
with the chronic suffering I have here alluded to ; ordinarily, and 
indeed in all the cases of this kind to which my attention has been 
called, the patients appeared to be perfectly well. One of these 
patients was thirty-three years of age, another twenty-seven, and a 
third twenty -two, and all of them were in perfectly good health. 
This is an argument, I think, in favor of the opinion just expressed, 
that the serious and annoying symptoms arise from the pathological 
condition of the uterus, or general conditions giving rise to it. The 
only symptoms these patients complained of at any time that seemed 
to be attributable to amenorrhcea were the backache, weight about the 
hips, etc., which denote the presence of the menstrual molimen. In 
the cases where amenorrhcea exists before the organs are sufficiently 
developed to assume the function of menstruation, we often observe a 
good state of health, even after the person has attained to an age when 
the menses are expected. I have had occasion to see, examine, and 
watch for several years two cases of chronic amenorrhcea from deficient 
development of the uterus, and perhaps of the ovaries. They were 
both married. One of them is twenty-eight years of age, has been 
married nine years, has never menstruated, has no sexual desires, but 
lives happily with her husband, and desires to be like other women 
merely to have a child for him. There are no distressing symptoms 
in her case. Her breasts and uterus are developed to about the size 
in a girl of thirteen years of age. There is hair upon the pubes, the 
mons is well developed, as is also the clitoris. The other has been 
married three years, is twenty-five years old, and resembles the first 
completely. 

When tuberculosis or other serious diseases cause amenorrhcea they 
are usually well manifested before the suppression occurs, but some- 
times this symptom shows itself so early in the case that it is regarded 
as the cause of the disease instead of the effect. 

From what is said above, the reader will see that suppression is a 
symptom of the absence, imperfection, or disease of some of the organs 
of generation, or is due to some grave deterioration of the blood or 
nervous energies, and that we are to look into all the circumstances 
which attend upon it, with a view to learn the causing conditions. 
We shall not always be fortunate enough to ascertain this, and we 
must then content ourselves with conjecture, and a necessary uncer- 
tainty in the treatment we adopt. 



286 AMENOREHCEA. 



Amenorrhea from Retention. 

If the retention dates from puberty the patient at the proper time 
began to experience the symptoms of menstruation. In instances 
where the retaining condition is acquired, the symptoms will be found 
to have followed close upon a severe inflammatory or ulcerated state 
of the uterus or vagina. After the retention is thus established by 
accident, the symptoms do not differ materially from those manifested 
where the occlusion is congenital. 

At first there are very moderate pains in the region of the uterus 
at each menstrual period. From month to month the pains increase 
in severity until they become excruciatingly severe. The pains at 
each menstrual epoch resemble those of labor, and cause the patient 
quite as much suffering. They are doubtless caused by the presence 
of the blood in the uterine cavity, and have for their object the expul- 
sion of that fluid. 

Soon after the establishment of this train of symptoms there ensues 
interparoxysmal suffering, much greater in some instances than others. 
There is a sense of weight in the pelvis and about the hips, weakness 
and pain in the back, dysuria, difficulty in evacuating the bowels on 
account of pressure upon the rectum, etc. 

There is, after the first few months, enlargement of the abdomen, 
which increases more slowly than in pregnancy. The tumor is of the 
shape and in the position of the uterus, and fluctuates obversely upon 
percussion. 

Diagnosis. 

It is not usually difficult to determine positively when there is 
amenorrhcea, and yet there may be good reason to doubt in some 
instances. It is not necessary that there should be an effusion of 
blood to constitute menstruation, for there are periodical discharges 
from the genital organs which indicate the process of ovulation, and, 
under certain conditions of the system, are more appropriate than an 
effusion of blood. I allude to a periodical discharge of mucus or 
sero-mucus. The uterine congestion is not sufficient in quantity or 
force to give rise to hemorrhage, but causes effusion of the thinner 
portions of the blood. 

We are often obliged to treat patients for a time without having 
more than their statements as a basis for our diagnosis, but fortu- 
nately, in most cases, this is sufficient. We are not justified, how- 
ever, in continuing the care of an obstinate case for any length of 
time without making an effort to verify or ascertain the fallacy of 
the grounds for our opinion. And, if need be, we must resort to 
physical examination. The fact of our patient being a virgin should 
cause deference, but not forbid an examination indispensable to a 



DIAGNOSIS. 287 

correct understanding of the cause of a condition that is destroying 
her life. I need only mention that suppression, attended with acute 
inflammation of the uterus and ovaries, will be attended with marked 
and almost invariably unmistakable symptoms. The pain, fever, 
tenderness, and sympathetic symptoms will leave no room for doubt. 
Ana?mia, cachexia, nursing, etc., are obvious conditions, and will be 
easily made out by very little attention. 

Correctness in diagnosis may be attained with great certainty when 
there is physical defect in the genital organs, by proper direct exami- 
nations of them, and they should be instituted when other means fail 
to satisfy us. The presence or absence of the uterus, in most instances, 
can be satisfactorily determined by introducing the finger into the rec- 
tum and a catheter into the bladder, and approximating them. If it is 
present, its thickness interposed between the two will prevent the finger 
from defining the shape of the instrument; if it is absent, they maybe 
made to touch with the intervention of the walls of the rectum and 
bladder. The catheter, in this examination, should be introduced 
deep into the bladder, and the finger as far up the rectum as possible. 
With this precaution, there can hardly be a mistake. I have met with 
several instances of congenital absence of the uterus, and in all the 
vaginae were absent, but each case presented all the external evidence 
of womanhood. The mons veneris was perfect and covered with hair, 
and the clitoris, labia majora, and breasts were well developed. The 
patients had the demeanor of women, and assured me that their desire 
for the society of men was as great as usual, and that they experienced 
strong sexual feeling. One of them had married, and was defending 
herself in a suit for divorce, upon the ground of her entire ignorance 
of any anatomical defect in organization ; another was about twenty- 
two years of age, and submitted to an examination with the hope of 
having a correction of the physical defect, preparatory to entering 
matrimony. It is possible that the vagina may be absent while the 
uterus is perfect in formation — the same examination will furnish us 
with proof — or the vagina may be occluded from defect of formation. 
This can be determined in the manner I shall presently describe. Ab- 
sence of the ovaries cannot always be determined by physical examin- 
ation, but there is generally such a. complete absence of the signs of 
womanhood in these cases that we cannot long hesitate. The mammse 
are not prominent, the manners peculiar to the sex, desire for the society 
of males, and sexual propensity, are absent. There is no hair on the 
pudenda, and the whole external organs are not developed. The signs 
are the same at any age. The patient at mature age presents no more 
evidence of sexuality than the little girl. 

I have very recently met with an instance of congenital atrophy of the 
uterus. The patient, although now twenty-eight years of age, has not 
menstruated, unless, as she doubtfully said, twice very scantily when 



288 AMEXOEEHGEA. 

about seventeen years of age. She is rather above medium size, and 
possesses all the characteristic appearances of womanhood. She has 
enjoyed fair health until the last twelve months. For the past year 
she has suffered from distressing palpitation of the heart, which almost 
incapacitates her for business. She has been married nine years. 
during which time she has enjoyed sexual intercourse indifferently. 
She has no monthly pains, no signs of menstrual congestion, and 
nothing by which to know when to expect that function. Her mammae 
are about the size in a girl of thirteen or fourteen years, the diameter 
being about two inches and a half, with a thickness at the nipple of 
about three-quarters of an inch. The nipples are very small. The 
labia and mons veneris are undeveloped, and the vaginal orifice is 
narrow. The uterus could be felt in its usual position or rather higher 
up in the pelvis, but was very light and small. When the fingers were 
placed under it in the vagina, and it was pressed down from above, it 
gave the sensation of diminutiveness, apparently not exceeding half its 
natural size. The ordinary uterine sound would not enter it more than 
half an inch. A probe with an extremity about a twelfth of an inch in 
diameter, freely passed up one inch and a half. From all this, it was 
plain that the uterus was in a state of atrophy ; and I infer that the 
ovaries were so, from the absence of the nervous signs of menstruation. 

The size of the organs, as measured by the plan above indicated, 
determines, together with the history of the case, that it is congenital 
atrophy. Acquired atrophy is confined generally to the uterus, while 
congenital atrophy generally involves all the genital organs, including 
the breasts and nipples. 

I have met with a number of instances of acquired atrophy, which 
by carefully tracing their history, I could attribute to early miscarriage 
which it seemed to follow. And this atrophied condition, doubtless, was 
hyperinvolution of the organ after abortion. In looking over the men- 
strual history of these sufferers, there was a time when they menstru- 
ated normally, and the function was disturbed after having been thus 
established. 

When amenorrhcea is attended by chronic inflammation of the uterus, 
a not unfrequent occurrence, the speculum and probe will reveal the 
condition beyond the probability of making a mistake. I have seen 
the worst forms of indigestion, and very great emaciation, attend this 
condition ; in fact, I have seen no other benign disease of the uterus 
produce so much emaciation as this. The patient is sometimes bed- 
ridden for months. In two instances recently cured by local treat- 
ment and proper dietetics and hygienic regulations, the patients had 
been reduced to two-thirds of their ordinary weight. 

Diagnosis of Retention. 

Upon examining the genital canal it will be found occluded at some 
point between the external labia and the internal os uteri. If the hy- 



PKOGNOSIS. 289 

men is imperforate the vagina cannot be penetrated. If the occlusion 
is higher up, it may be found by the finger and probe. By intro- 
ducing the finger into the rectum and a catheter into the urethra, the 
bladder and rectum will be found widely separated, the catheter pass- 
ing up close behind the pubis, and the finger being pressed strongly 
against the sacrum. The finger in the rectum will easily determine 
how near the external organs the obstruction is. 

The history, the non-appearance of the menstrual fluid, the slow 
enlargement of the abdomen, periodic painful paroxysms, and the oc- 
clusion of some part of the vagina or uterine cervix, are quite enough 
to distinguish it in most cases. 

Auscultation and palpation will establish the diagnosis between re- 
tention and pregnancy. 

Prognosis. 

The curability of amenorrhea will depend on the causing condi- 
tions. When occlusion of some portion of the genital canal prevents 
the discharge of the menses, we can usually, by surgical means, evacu- 
ate it, and establish an outlet for the future. Although simple and 
easy of accomplishment, the evacuation of a long-retained and consid- 
erable accumulation is always attended with hazard. In the first 
place, inflammation may foil our efforts to establish a permanent via- 
duct for the blood which may be discharged from the uterine vessels ; 
and in the second, this process may be so great and extend to the 
peritoneum in sufficient intensity as to cause the death of the patient. 
Amenorrhcea from ansemia may be pretty surely cured ; it is the cur- 
able variety compared with those occurring from other causes. When 
arising from inflammation, it will also generally yield to appropriate 
treatment, as the cure wholly depends upon the removal of the caus- 
ing conditions. The cachexia which may produce amenorrhcea are 
often entirely incurable, and, therefore, our prognosis must be unfavor- 
able when they are associated. 

In cases of absence of the ovaries or uterus, we cannot expect to do 
good by treatment. Where there is only atrophy of the organs, we 
may hope that some of the ingenious contrivances to increase their 
development which our profession of the present day affords (they 
have almost all emanated from, or been perfected by, the fertile genius 
of Professor Simpson, of Edinburgh), may enable us to succeed. It 
cannot be concealed, however, that these causing conditions will often 
resist every means within our reach. To sum up, then, according to 
my observation, when suppression arises from any other causing con- 
dition than general ansemia, or inflammation of the uterus or ovaries, 
the prognosis is not very promising, and we should be cautious in 
promising a speedy and permanent cure. Failure in the function of 
menstruation is pretty sure to be accompanied with an inability for 

Vj 



290 AMENORRHCEA. 

conception ; imperfection of it is, likewise, very frequently an evidence 
of barrenness. This is particularly the case with scantiness. When 
menstruation is infrequent, but the function is otherwise perfect, the 
patient is often prolific. I have known a woman for several years, 
who does not menstruate more than three times in a year, and then 
not at regular intervals, and yet in the last six years she has had two 
children, conception following immediately after one of these irregular 
menstrual discharges. 

Treatment. 

We should always bear in mind the fact that amenorrhcea is but a 
symptom, and endeavor to amend the condition or disease upon which 
it depends. This rational mode of procedure, however, is not always 
practicable, for unfortunately, as has been more than once stated, we 
cannot in ever} T instance ascertain precisely the condition. In such 
cases we make use of remedies, or plans of treatment, which, from the 
success that has occasionally followed their use, have gained the title of 
emmenagogues. This term signifies promoter of menstruation. Are 
there any direct emmenagogues ? I think, in the nature of things, 
there cannot be. To cause a flow of the menses proper, which depends 
upon ovulation for its existence, they must produce or promote the 
evolution of ova. That there are remedies and plans of treatment 
which indirectly promote the menstrual discharge I think there is 
ven T little doubt. In a general way we ought to consider this class of 
remedies as producing their effects in two different modes, one by 
causing the growth and production of ova, and the other the discharge 
of blood as a hemorrhage. It would be better, then, to say that they 
are oviferous in their nature in the first case and hemorrhagic in the 
second. To the first order belong the preparations of iron and other 
mineral and vegetable tonics, nutritious diet, exercise in the open air, 
diversion of mind, travel, sea-bathing, and in fact, everything which, 
by correcting derangement of the vital organs and generating good 
blood and plenty of it, is promotive of healthy functional action gen- 
erally. To the second belong aloes, savin, cantharides, and any hy- 
gienic measures which determine blood to the pelvic organs, as foot-, 
hip-, and leg-baths, sinapisms to the feet or legs, etc. In many instances 
they may very properly be combined. 

When amenorrhcea results from cold applied to the surface or lower 
extremities, or from any cause suddenly acting to suppress the flow, 
the uterus and ovaries are bordering on, if not in, a state of acute 
inflammation, and the remedies for it should be directed to the relief 
of the diseased organ or organs. The question very naturally arises, 
can we, or ought we do anything to cause the return of the flow im- 
mediately upon its suppression, and if so, what? Experience teaches 
us that if the flow can be reproduced in a very few hours after its sup- 



TREATMENT. 291 

pression, before general reaction occurs, the turgid and phlogosed con- 
dition of the sexual apparatus may subside into a condition of health, 
and that this can sometimes be done by judiciously managed stimula- 
tion ; but if the flow is not re-established in a few hours, we need not 
expect it to recur until the next period, if then, and it is injudicious to 
continue stimulation beyond a very short period. Then what is the 
proper course of stimulation? If our attention is called to the case 
within a few hours, and there is not much febrile reaction, we may 
very properly direct a hot bath to the whole person of the patient 
below the waist for half an hour. The patient should then be put in 
bed, and large sinapisms placed upon the inner portion of the thighs 
and hypogastrium, and allowed to remain until a strong rubefacient 
effect is produced, when they may be removed, and the whole replaced 
by a hot linseed-meal poultice. While these measures are being ac- 
complished, we should administer copious draughts of some kind of 
warm tea. I cannot approve of the gin-slings or toddies given so freely 
under these circumstances ; they often do harm by their excessive 
stimulation, rendering the inflammation a fixed evil. 

Should the flux not return in twenty-four hours from the time of 
suppression, it would be unreasonable to expect and injudicious to 
continue treatment to cause it to do so. It then remains for us, if 
possible, to remove the phlogosed condition of the organs, so that they 
may be in a state to resume their functions at the return of the next 
ensuing menstrual period. 

It will be found, I think, that for the first month, in case of an acute 
suppression, especially in plethoric patients, the most successful course 
of treatment will consist in moderate antiphlogistic and alterative 
means, kept up steadily. The one I have ordinarily followed consists 
of counter-irritants to the hypogastric region ; the hip-bath of tepid 
water twice a day ; six to ten grains of blue mass every third night, to 
be followed in the morning by a seidlitz powder ; and abstinence from 
all stimulants and highly seasoned food. If, however, the suppression 
continue beyond the second period after the suppression, it may be 
attended with chronic inflammation, with or without general anaemia 
etc., and will come under some of the conditions hereafter to be 
considered. 

Amenorrhcea connected with chronic inflammation of the uterus or 
ovaries may be treated as I have elsewhere directed those affections to 
be managed. I think that it is not very common for suppression, in 
the chronic form, to depend upon inflammation alone. More frequently 
the causes of amenorrhcea exist in the condition of these organs that 
remains after inflammation, such as condensation of fibrous tissue, 
either with or without atrophy. The same treatment, with little vari- 
ation, is applicable to both. I shall have occasion to detail the treat- 
ment in speaking of atrophy and want of development. 



292 AMENORRHEA. 

Another condition which succeeds inflammation of the uterus and 
ovaries, after an acute suppression, is anaemia. For there certainly are 
cases in which an impoverished state of the blood succeeds an acute 
suppression, and in turn prevents the re-establishment of the flow. A 
tonic, roborant treatment, applicable to anaemia arising from other 
causes, may be instituted, if need be, even before the inflammatory 
condition of these organs has entirely subsided. Perhaps a little more 
attention to alteratives, in connection with the tonics, is necessary in 
this class of cases. When anaemia is the primary condition upon 
which amenorrhcea depends, it will almost always be found depen- 
dent upon some preceding affection. Indigestion, connected with a 
slow or depraved state of the secretions of the alimentary canal, often, 
by preventing the introduction of nutritious elements into the blood, 
induces anaemia. This condition arises, for the most part, in one of 
two ways, — either the nervous energy necessary to the sustenance of 
the functions is diverted toother objects, as mental training in the 
school-girl, or the circulation in the abdominal organs is too sluggish 
on account of sedentary habits, as with the sewing-girl. Sometimes 
want of exercise and too great a tax upon the brain from studies, 
anxiety, etc., co-operate in the same individual. Anaemia may be 
produced by a great variety of causes besides those above mentioned, 
but, according to my experience, these are far the most frequent. I 
Avould not have the reader believe, because I have given the school- 
girl and the sewing-girl as instances of amenorrhoea, that they are the 
only persons in whom the same character of causes operate in the 
same way. Very many fashionable young ladies, who might enjoy 
the blessings of relaxed, diverted, or healthily employed minds, and 
appropriate and enlivening exercise, become ansemic from sheer lazi- 
ness and the nervous anxiety connected with envy. 

Bearing in mind, then, the causes of indigestion and anaemia, we 
must, first of all, thoroughly revolutionize the habits and circumstances 
of the patient, making plenty of outdoor exercise one of the main 
conditions. Riding in a carriage is not outdoor exercise for these pa- 
tients ; they must ride on horseback, or, what is very well, walk, run 
and romp. An excellent sort of diversion for the mind is occupation 
in domestic duties, making beds, sweeping, cooking, washing, caring 
for and attending children, etc. The mind and body are both em- 
ployed in a varied and diverse manner in these household duties, and 
it will be found that exercise both of body and mind is most profit- 
able as it is most diverse and varied. While it is true that some kinds 
of exercise, as walking or riding, may be made to call into play a great 
many muscles, yet the whole routine of duties presenting themselves 
in the business of housekeeping, by personally doing the work, is more 
beneficial than all others devised. This lesson is taught by the con- 
trast between the young mistress and her servant. 



TREATMENT. 293 

In addition to the adoption of a more rational course of habits for 
the patient, much may be clone by the judicious use of medicines. 
Almost invariably the tonics must be preceded by, or accompanied 
with, alteratives and laxatives. The stomach will no more recognize 
and respond properly to a tonic that is introduced into it until pre- 
pared by correcting the secretions, quickening the gastric circulation, 
and unloading the bowels, than it will digest food under similar cir- 
cumstances. The alteratives suitable, generally, are mercury in some 
form, taraxacum, and turpentine. When the bowels are torpid, the 
stools dry and of unnatural color, particularly if the color is light, 
from three to six grains of blue mass given every third night, and fol- 
lowed next morning by a seidlitz powder, or sufficient sulphate of 
magnesia to cause one or two evacuations, is an admirable alterative- 
Ten grains of good extract of taraxacum, with a minute quantity, say 
the twentieth of a grain, of bichloride or biniodide of mercury, three 
times a day for two or three days, generally does very well. The 
mercury should not be given with the taraxacum longer than three 
days, and then intermitted for a week, but the taraxacum may be given 
steadily for weeks. An excellent alterative for the stomach is Venice 
turpentine. Ten grains three times a da}' after eating, on sugar, alter- 
nated or given with some of the mercurial preparations, proves often 
of great service. I cannot but mention the compound confection of 
black pepper, made in imitation of Ward's paste, as having frequently 
an excellent laxative and corrective effect on a weak state of the stom- 
ach accompanied with constipation. I have known it to cure some of 
the most obstinate cases of constipation attended with anaemia. 

If there is not scantiness of secretions, but slowness of peristaltic 
movement, we ought to depend on rhubarb and aloes. The compound 
aloetic pill is a good preparation. In the selection of tonics we should 
bear in mind the difference between the stomachic and blood tonics. 
Iron is, perhaps, the only direct blood tonic, while there are a great 
many articles that act as stomachics. Almost all the bitter vegetables 
ranged under that head in the books are useful under certain circum- 
stances. The stomach tonics, by improving digestion, are indirectly 
blood tonics, so that they are sometimes all that are necessary. In 
many instances, too, the stomach must be prompted by the bitters, or 
other stomachics, before it will absorb or assimilate iron. The bitter 
may precede the iron, or be administered simultaneously with it. It 
is sometimes convenient and profitable to combine the alterative and 
stomach tonic. A mixture of this kind, often used, is the compound 
tincture of cinchona, with bichloride of mercury dissolved in it. 
The tincture of gentian, or colomba, answers very well compounded 
w r ith mercury. Extract of gentian and Quevenne's iron compounded 
in a pill produce good results on the ansemic patient. If we under- 
stand the principle that governs the treatment in such cases, we may 



294 AMENORRHCEA. 

readily find the means to accomplish our ends, by alteratives, stom- 
ach tonics, and blood tonics. 

The cachexia?, several of which interfere with the regularity of the 
function of menstruation, must be treated as if the menses were present 
in their normal quantity, and in these cases the amenorrhceal compli- 
cation is of no importance, hence special efforts to restore the flow are 
injudicious, and in most cases injurious. 

In cases of defective nervous energy we may expect benefit from the 
direct application of electricity to the uterus, or to the nerves that 
supply it. In a paper read before the Xew York State Medical Society. 
by A. D. Rockwell, M.D.,* I find the following statement : 

"Amenorrhea is a symptom that yields, perhaps, more readily to some one of the 
many forms of electrization than to any or all other methods of treatment. In cases 
dependent on, or associated with, general debility, general electrizatir n is of course 
indicated ; but where all external efforts have been fruitless, internal electrization is not 
infrequently followed by an immediate and satisfactory flow." 

He gives a case as illustrative of the efficacy of his method of per- 
forming local electrization : 

"I introduced a cup-shaped metallic electrode to the uterus, so that the os was com 
pletely surrounded, and applied the positive pole firmly against the abdomen im- 
mediately above the pubes. The current, which was of considerable strength, I reversed 
rapidly a number of times during the seance, and on the following day repeated the 
application. In less than six hours after making the second attempt, slight signs of 
returning menstruation were manifest, and steadily increased until, as regards quantity, 
the flow was quite natural. The patient was immediately relieved of all her distressing 
spasmodic symptoms, and at the present time (three weeks having elapsed since the 
treatment) still remains free from them." 

Query. Was this menstruation or metrorrhagia ? 
Dr. Parvin. in the same journal, says : 

" The positive electrode passed into the uterine cavity, the negative applied to the 
hypogastrium, gives oftentimes a very prompt success in inducing a sanguineous dis- 
charge from the uterus; but in order that such result should follow, this means should 
be used only at a time when the other phenomena of menstruation manifest themselves, 
the flow only wanting." 

The faradic is the form of electrization recommended by both these 
gentlemen. 

In patients well developed in most respects, whose genital system 
is deficient, the menses cannot be produced unless these organs grow 
and become more active. Anything that will stimulate these organs 
will occasionally bring this result about. Wedlock is a remedy some- 
times. The indulgence in society, and the recreations of it, in com- 
pany with men, sometimes, through the moral faculties, stimulate the 



* American Practitioner, Mav, 1872. 



TREATMENT. 295 

genital organs towards development. The stimulus thus afforded by 
society is one of the beneficial effects resulting from the change of 
habits in young girls who go to boarding-schools until sexually dwarfed 
by confinement to the uninteresting society of their own sex. 

Sir James Y. Simpson has recommended an instrument, which he 
calls an " intrauterine pessary," to bring about this development. It is 
equally applicable to cases of atrophy of the uterus arising after the 
menses have been established. I have had occasion to use it, and am 
now employing it in the interesting case to which I have alluded above. 
It is theoretically better, I am afraid, than it will be found practically ; 
yet no doubt much good may be done by it. The object of the intra- 
uterine pessary is that it may be the medium, or generator, rather, of 
galvanism, to stimulate the nerves of the uterus. 

Both of these effects are promotive of uterine hemorrhage, if not of 
correct menstruation. They are necessary to the development of an 
atrophied uterus, whether congenital or acquired. But this instrument 
is recommended and used in obstinate cases of amenorrhcea, where there 
is no apparent deficiency in the size and development of the organs 
concerned. It is in this class of cases that most may be effected by it, 
and yet it sometimes entirely fails to produce any effect. To do good 
in the cases of atrophy and want of development it should be used 
continuously. Where the development is good, I am inclined to think 
that the pessary will do more good by using it intermittingly. In 
these cases we may introduce the instrument one week before the 
time of the expected period, and allow it to remain, and then, after the 
time is passed, remove it, and again introduce it at the proper time. 
We should remember that we cannot use an instrument of the same 
size in all cases. In the uterus that is much atrophied it would be 
violence to use an instrument that is applicable to a fully developed 
organ. In the former we must have an instrument that will pass into 
it easily, and in a couple of months use one larger; and after the lapse 
of a similar time make another one still larger, etc., until development 
is complete. The instrument is made of copper and zinc, and consists 
of a stem and bulb. The bulb is hollow, in order to be light as pos- 
sible, flattened, and oval in shape, one inch long, three-quarters of an 
inch wide, and half an inch thick. It should be perforated through 
its thinnest diameter by a hole two-twelfths of an inth in diameter. 
Into this perforation the stem is to be inserted. The stem should be 
two inches long for a uterus not atrophied, and as much less as is 
necessary, in the judgment of the attendant, when atrophy has taken 
place. It should be hollow and light like the bulb. The bulb, and 
one inch of the stem next the bulb, is made of copper, the extremity 
of the stem of zinc. This completes the instrument as made and used 
by Professor Simpson. I find, in some instances, great difficulty, if 
not an entire impracticability, in wearing it, on account of its tendency 



296 AMEXOEEHCEA. 

to fall out. Sometimes, too, the galvanic stimulus is not sufficient. On 
these accounts I have made an addition to it, which, I think, adds to 
its efficiency as well as to security of position. This consists of a zinc 
ball, about an inch in diameter, attached to a copper rod four inches 
long. The ball is introduced into the vagina after the intrauterine 
pessary has been introduced, while the stem is attached to a frame- 
work outside the pelvis to keep the whole in position. As will be seen 
by a study of this apparatus we have quite a galvanic battery, the 
copper rod reaching from the framework of zinc outside to the zinc 
ball inside, this last lying in contact with the copper bulb of the 
pessary, etc. If we do not desire any galvanism the whole apparatus 
can be made of copper. Made in this way the instrument is quite 
efficient. The young physician or student may be embarrassed in 
his attempts to introduce the pessary without a little consideration. 
The plan I have found most convenient is, to expose the os uteri by 
means of the bivalve speculum ; secondly, to secure the pessary by in- 
serting a piece of whalebone, properly shaped, in the perforation in 
the bulb ; thirdly, thus mounted, to insert the stem, and with great 
gentleness urge it forward to its full length, or until it is arrested by 
the contracted internal os uteri or the end touching the fundus. If 
this arrest occurs the instrument is either too large or too long, and 
must be replaced by one more suitable in this respect. After the pes- 
sary is inserted we may withdraw the speculum, and, if necessary, 
apply the ball and external framework above described to keep it in 
position. All this direction does not include a fact which should ever 
be borne in mind by the student, viz.. that sometimes the instrument 
is utterly intolerable ; and, at others, a good deal of address and pa- 
tience is required to habituate the parts to it. The patient should be 
forewarned that pain and inflammation are the possible effects, and that 
she must inform us should they be considerable. There is always some 
pain, sometimes a great deal. When the irritation is too severe the 
instrument must be removed, quietude observed, and, if necessary, 
anodynes, and even antiphlogistic treatment must be resorted to, to 
remove the symptoms. After all these have subsided it may be again 
introduced. A little perseverance and care will render most cases 
tolerant of its presence. During the time the instrument is used the 
vagina must bf thoroughly cleansed, at least twice a day. with tepid, 
warm, or cold water, and fine soap, used as injections. 

For the treatment of Amenorrhcea by retention the reader is referred 
to the Treatment of Atresia and Absence of the Vagina. 



CHAPTEE XL 

MENORRHAGIA AND METRORRHAGIA. 

Hemorrhage occurring at the time of menstruation beyond the 
usual quantity is menorrhagia. Hemorrhages occurring at other times 
do not belong to this denomination, but are called metrorrhagia. 
Often both metrorrhagia and menorrhagia occur in the same individual, 
which depend upon the same conditions of the system or reproduc- 
tive organs, and are alike symptomatic of some local or general dis- 
ease. 

It is not difficult to understand that an exaggeration of the hyper- 
emia, or an unusually rapid disintegration of the uterine mucous 
membrane, would cause more than a normal amount of flow, nor that 
a want of accordance in time might be followed by the same result. 
Indeed most cases of uterine hemorrhage are traceable to conditions 
which disturb the equilibrium of these phenomena. The causes which 
thus act are varied and numerous. 

Morbid nervous influences, which increase the discharge of blood from 
the uterus, sometimes emanate from the nervous centres, and hence 
may be properly termed centric; much more frequently, however, they 
are reflected through the nervous centres from other and sometimes 
distant organs, and these last are entitled to the denomination of reflex 
or eccentric nervous influences. 

Mental and emotional excitement emanating directly from the brain, 
and cerebral and spinal excitement originating in inflammation or 
functional exhaustion of the brain or spinal cord, are examples of 
centric etiological influences. Many years ago I witnessed the ravages 
of an epidemic of cerebro-spinal inflammation, in which uterine hem- 
orrhage was of almost universal occurrence among those adult fe- 
males who fell under its influences. 

Morbid reflex nervous influences afford a more numerous class of 
causes. First among them, both in frequency and importance, are 
those arising from abnormal conditions of the ovaries, such as conges- 
tion, inflammation, displacement, and erotic excitement. Next to the 
influence of these bodies is that exerted by the mammary glands. 
Menstruation is generally more profuse when it occurs during lactation. 
The effect of mammary irritation in causing congestion of the uterus, 
and thus promoting hemorrhage from it, is well illustrated by the 
familiar fact that sinapisms or blisters applied to the breast will often 
cause metrorrhagia. Vesical irritation, or inflammation, which gives 
rise to tenesmus, rectal irritation, as from the presence of hemorrhoids 



298 MENORRHAGIA AND METRORRHAGIA. 

or ascarides, and dysenteric inflammation, through the reflex influence 
which they exert upon the uterus, are generally recognized causes of 
uterine hemorrhage. Among other reflex causes may be mentioned 
certain forms of indigestion, hepatic congestion and inflammation, and 
some of the disturbances of the small intestines, as may also strong 
impressions upon the cutaneous surface, as from cold, or from the 
long-continued application of heat in warm climates and seasons. 

All of these last-mentioned causes I think act through the reflex 
system of spinal nerves, and perhaps also through the agency of the 
sympathetic ganglia, which perform a reflex function between the 
viscera. The morbid effects of the various reflex nervous impressions 
are rendered more effective and intense by the presence of such uterine 
diseases as predispose to hemorrhage by increasing the vascularity of 
the uterus. 

Many pathological conditions which conduce to the production of 
uterine hemorrhage, independently of direct nervous influence, act by 
increasing the hyperemia of the uterus. When the mucous membrane 
is granulated, or is the seat of inflammation, of fibrous polypus, or of 
malignant fungus, the circulation of the uterus is increased, and har- 
mony in the process of nidation disturbed ; and these conditions will 
be accompanied by an unusual and long-continued flow of blood. 
Subinvolution, congestion and inflammation, hyperplasia, tuberculosis, 
cancerous and fibrous deposits in the muscular structure, and chronic 
and acute endometritis, in addition to preventing the normal decidu- 
ous changes in the mucous membrane of the uterus, maintain a per- 
manent hyperemia, and thus render the womb prone to large losses at 
each return of the menstrual period. We have, in fact, abundant rea- 
sons for assuming that chronic hyperemia, no matter how produced, 
will, by virtue of the malnutrition connected with it, prevent menstrual 
changes from being effected in an orderly manner, and thus render 
the mucous membrane more frail in organization, and consequently 
incapable of resisting the force of vascular pressure to which it is 
periodically subjected. 

Besides the causes of uterine hyperemia last alluded to, and exist- 
ing within the tissues of the womb, there are many other outside patho- 
logical conditions acting in a different way. Some of these cause venous 
hyperemia by mechanical retardation of the circulation, while others 
give rise to both arterial and venous hyperemia by nutritional attrac- 
tion, and others again cause arterial hyperemia alone, by forcing un- 
usual amounts of blood into the organ. Among the most frequent 
and important causes of venous retardation are displacements and 
flexions of the uterus — procidentia, retroversion, and retroflexion — 
the former by stretching the veins and rendering their course more 
tortuous, the latter by twisting them, and thus lessening their calibre ; 
exudations into the cellular tissue and peritoneal pouch, from cellulitis 



CAUSES OF MENORRHAGIA. 299 

and local peritonitis, and effusions of blood in the cul-de-sac of Doug- 
las, in retro-uterine hematocele, by pressing upon the veins, prevent a 
free return of. blood from the uterus, and thus cause venous hyperemia. 
Retardation of movement in the uterine veins may also be caused by 
obstruction to the venous circulation quite remote from the womb, as 
by the pressure of a tumor upon the ascending vena cava, by a loaded 
condition of the large intestine, by dislocation or enlargement of the 
liver, by obstruction to the free passage of blood through the heart from 
vulvular disease, and even by certain pulmonary affections. 

In the class of causes giving rise to both arterial and venous hyper- 
emia may be mentioned fibrous, fibrocystic, polypoid, and fungous 
growths of the fibrous structure of the uterus. These all increase the 
flow of blood to and through the vessels of the uterus, both arteries 
and veins are increased in capacity, and to these changes is added 
general hypertrophy. In these cases the hyperemia of all the tissues 
is sometimes enormously great, and the losses of blood are propor- 
tionally large and dangerous ; the hemorrhage, unlike that from venous 
obstruction, is not checked by the emptying of the vessels, but contin- 
ues until the arterial and cardiac vis-a-tergo is weakened by approach- 
ing syncope. 

Causes producing arterial hyperemia alone are hypertrophy of the 
heart, general plethora, febrile excitement, and violent exercise. The 
uterine hj'peremia in these cases is caused by unusual arterial and 
cardiac pressure alone. When not attended by local pathological con- 
ditions, the hemorrhage in these cases is not apt to be serious. 

Other not uncommon causes of hemorrhage from the womb are vari- 
ous diseases of the blood. Among these may be mentioned scurvy, leu- 
cocy themia, chlorosis, albuminuria, and syphilis. It is not likely that 
the vice in the composition of the blood is the sole causative influence 
operating in the above named conditions. In scurvy, for instance, we 
know that the solid tissues, whether as a primary condition or as an 
effect of the blood-changes, are diseased, the capillaries more fragile 
than natural, and, consequently, less capable of resisting the cardiac 
impulse. As evidence that the vicious condition of both blood and solid 
tissues is the cause of uterine hemorrhage in scurvy, the well-known 
fact may be added that bleeding is very easily provoked in other mu- 
cous membranes. It is the more likely to take place from the mucous 
membrane of the uterus, because of the great normal fluctuations in 
the circulation of that organ, and also because the vitiated state of the 
blood would naturally cause disturbance in other conditions attendant 
upon menstruation, especially the decidual changes. It will be seen 
therefore that the peculiarity in the operation of this variety of cause 
is not due to the presence of local or general hyperemia from retarda- 
tion of the venous circulation, or from arterial and cardiac pressure, 
but is due to the tendency of the blood to escape through the walls of 



300 MENORRHAGIA AND METRORRHAGIA. 

the vessels, and to the inability of the capillary tubes to resist the cir- 
culatory force ordinarily applied to them. 

As another cause of hemorrhage from the womb must be mentioned 
the well-known law of the human system, to continue a long-established 
habit after the original cause is removed. This is probably the only 
rational explanation of those rare uterine losses which are sometimes 
observed in pregnancy and in cases where both ovaries have been re- 
moved. The habit of bleeding continues after the ovarian reflex ner- 
vous influence has been withdrawn from the uterus. 

Still another rare yet very dangerous cause of uterine hemorrhage is 
that known to surgeons as the hemorrhagic diathesis. The writer has 
seen one case in which he believes that the bleeding was clearly at- 
tributable to this mysterious condition, and which proved fatal. It 
was that of a young girl who died with her second menstrual flow. 

The wide range of causative conditions found connected with uterine 
hemorrhage is but an inverse exhibition of the sympathetic relations 
of the uterus. When diseased, it exercises an almost universal patho- 
logical influence upon other organs, and, as a consequence, it is sus- 
ceptible of being impressed to the same degree by certain morbid 
conditions of all important viscera. It will not be regarded as making 
an undue claim to say that the practice of gynecology requires a more 
thorough theoretical and practical familiarity with the details of all 
the branches of medicine than any other of the so-called specialties. 
We are not prepared to treat the most common of female diseases 
without being able to scan with scientific scrutiny every organ and 
function of the body. Nor until we can compete successfully with 
the general practitioner, the surgeon, the alienist, and the neurologist 
in the therapeutic processes of their respective departments may we 
hope to exercise in the highest sense the office of the gynecologist. 
These remarks apply with force to the comprehension of the causes 
and treatment of hemorrhages of the unimpregnated and non-puer- 
peral uterus. 

Treatment of Menorrhagia. 

I find it quite impossible to satisfy myself as to the best order in 
which to bring forward the various measures proposed for treating 
uterine hemorrhage. Those which have for their object the removal 
of the causing conditions, properly fall under the head of curative 
means ; while those which we employ to stop the bleeding tempo- 
rarily, until the remedies of the first order have accomplished their 
purpose, seem as naturally to belong to the category of palliative 
measures. We find in each of these divisions, however, remedies 
which act in both ways, and the palliative means are often radical 
and energetic. Notwithstanding the many obvious deficiencies in 
this arrangement, it seems to me to be the best that I can adopt. 



TREATMENT OF MENORRHAGIA. 301 



Palliative Treatment. 



Before entering into a detailed description of the more essential 
remedial methods of curing the various forms of hemorrhage it will 
be profitable to consider some of the important minor measures which 
are applicable in almost all instances. As the great majority of 
hemorrhages occur at the menstrual periods, we often have oppor- 
tunities of adopting measures in anticipation of them. These meas- 
ures are sometimes calculated to entirely prevent an exaggerated flow, 
and at others to very much modify it ; and in all to greatly promote 
the action of more direct remedies. The patient should abstain from 
all causes of local or general vascular or nervous excitement. Among 
these causes are mental and bodily fatigue, emotional excitement 
arising from certain social relations, sensational books, and the con- 
templation of erotic objects. The patient should also abstain from 
stimulating drinks and highly seasoned food ; her clothing should be 
loose and cool, so that no part of the body may be constricted, and 
the genital organs should not be too warmly covered. Her bowels 
ought to be kept regular, or rather free. The secretions from the skin, 
liver, and kidneys should be maintained as nearly as possible in a 
normal condition, and tonics, such as arsenic, strychnia, and quinia, 
with digestible, nourishing, and unstimulating diet, should be given 
in quantities sufficient to keep the health up to the normal standard. 
Other things which will contribute very greatly to good results are 
plenty of pure air, night and day, and moderate muscular exercise. 
Many other general directions will suggest themselves, which I cannot 
stop now to mention. 

When the time for the paroxysm has arrived, and the hemorrhage 
has commenced, isolation, quietude, and recumbency are very im- 
portant precautions to be enjoined. Position, indeed, may be made 
to do much good of itself. If the hemorrhage is not severe, mere 
recumbency will be sufficient; but if it is protracted, the hips should 
be elevated, and sometimes it will be beneficial to raise them so high 
as to cause the blood to gravitate to the fundus uteri, and to fill the 
whole genital canal before any of it passes out. To a considerable 
extent this may be made to act as a tampon. The position chosen to 
effect this object may be on the back, or upon the knees and chest. 
If the latter position can be commanded, it is much the best, as the 
reversal of gravitation is more complete. Cold and acid drinks, cold 
applications to the hypogastric and sacral regions, hips, and vulva, 
and in the vagina, are also among the remedies suitable to almost 
all cases. Many practitioners value astringents, administered in- 
ternally, in uterine hemorrhage, but I have found so little benefit 
from them when not given with opium or belladonna, that I seldom 
resort to them. Where there is much pain in the pelvis, and a dry 
state of the skin, opium and ipecacuanha are often very serviceable. 



302 MENORRHAGIA AND METRORRHAGIA. 

Lobelia, gelsemium, digitalis, aconite, and veratrum viride, may also 
be mentioned as very frequently applicable where there is vascular 
and nervous excitement. 

Perhaps the medicine most generally applicable in paroxysms of 
uterine hemorrhage, is ergot. In all cases of local arterial hyperemia, 
as in tumors, hyperinvolution, etc., we may expect good from its 
employment. But it will generally fail to be useful when the uterine 
hyperemia is venous, as in retroversion, pelvic infarction from peri- 
uterine effusion, abdominal tumors, etc. It will not act efficiently in 
cases of carcinomatous deposit, granulations of the mucous membrane, 
or tuberculous degeneration of the fibrous texture of the uterus. 

In the more dangerous instances of hemorrhage, these moderate 
palliative measures are not sufficient. In some, the amount of loss is 
so great, and occurs so suddenly, as to threaten the life of the patient. 
Or, if life be not in danger, the discharge may be sufficient to lead to 
other very serious remote consequences. These emergencies are to be 
met by such means as will promptly arrest the flow, and keep it in 
check until curative processes can be instituted. Fortunately this 
may be done with great certainty by mechanical and chemical appli- 
ances generally at our command. The genital canal, practically closed 
at its upper extremity, and conveniently open at its lower termination, 
admits of being impacted to an impermeable degree, and allows of 
topical applications to its whole extent. In using either form of these 
topical measures, the effort should be made to apply the remedy as 
near to the bleeding point as possible. 

When practicable, we may secure the best effects by employing the 
mechanical and chemical means conjointly. The mechanical means 
embrace the different forms of the tampon. Plugging arrests the 
hemorrhage by forcibly opposing the evacuation of the blood, and b}^ 
thus imprisoning it in the smallest cavity. The blood so confined, 
coagulates, and fills the space between the tampon and the bleeding 
surface with a fibrinous clot, which also closes the mouths of the 
vessels. When plugging is skilfully performed, the relief is tempo- 
rarily perfect, and gives us valuable time for other treatment, or allows 
the cyclical period to pass, when the hypersemia subsides. The chemical 
means consist in the use of powerful haemostatics. By their chemical 
action upon the solid constituents of the blood, they produce a much 
firmer coagulum than results from mere stasis, and, if applied to the 
ruptured vessels, seal them up with coagulated plastic material, while 
if further away the coagulum forms a chemical tampon which opposes 
the flow toward the vulva. Used with the mechanical tampon they 
may be made to fill the interstices of the material of which it is formed, 
and thus solidify the whole mass. 

In the greater number of dangerous cases of the kind of uterine 
hemorrhage, the mouth of the womb is sufficiently patent to permit 



TREATMENT OF MENORRHAGIA. 303 

the introduction of the plugging material saturated with a haemostatic 
preparation into the cavity of the uterus. Dr. Sims's method of pre- 
paring the material and performing the operation of plugging the 
womb is admirable in its simplicity and efficiency. The substance 
used is the finest article of cotton -wool, saturated with a liquid com- 
posed of one part of the strong solution of the subsulphate of iron and 
two of water. After the cotton has been perfectly saturated, it is de- 
prived of the major part of its fluid by pressure, and is then allowed 
to dry until ready for use. The application is made by wrapping a 
sufficient quantity of the dried iron-cotton around a long, small piece 
of whalebone, and introducing it into the cavity of the uterus, when 
the cotton is detached and left there. If the hemorrhage is compara- 
tively moderate, one of these pieces may be sufficient ; if severe, it will 
be necessary to stuff the uterine cavity full. This can be best accom- 
plished by having the patient placed on her side, and the uterus ex- 
posed by Sims's speculum. To facilitate the removal of this ferruginous 
tampon, the suggestion of Dr. J. R. Chadwick, of Boston, is, I think, a 
valuable one, viz., to wrap strong thread loosely around the cotton as 
it surrounds the whalebone. I prefer this method of using the haemos- 
tatic to its injection, because the shock from the application is much 
less. 

If the mouth and cervical cavity of the womb are not sufficiently 
open to permit of the introduction of this haemostatic preparation, we 
may plug the cervix with prepared sponge. The first sponge should 
be pushed through the cervix into the cavity, and up to the fundus 
uteri, so that when it expands its upper end may possibly reach and 
press upon the bleeding point. If large enough, the cervical cavity 
will be completely filled and the bleeding effectually checked. The 
sponge should be carbolized, and w T ell secured, before it is introduced, 
by passing a strong piece of twine through it, from one end to the 
other. Neither the cotton nor sponge should be allowed to remain 
longer than twenty-four hours, and half of that time is usually long 
enough. After removal, the vagina may be cleansed, and the applica- 
tion repeated if necessary. I have sometimes been obliged to renew 
the sponge tampon several times in the same case, though this is not 
usually required. 

If these means are not at hand, or if the case is not sufficiently 
urgent to require plugging of tne uterus, we may resort to the vaginal 
tampon. This may be made of cotton, of which pieces as large as 
pullet's eggs may be used, rolled somewhat solidly, and each secured 
with thread and lubricated with oil or lard. A sufficient number to 
perfectly fill the vagina should be prepared. The patient should be 
placed on her left side, with the limbs flexed, and the upper one thrown 
forward over the other. The operator, standing at the back of the 
patient, inserts into the vagina two fingers of the left hand, with which 



304 MENORRHAGIA AND METRORRHAGIA. 

he draws the perineum well backward. This will open the canal so that 
the clots may be easily removed with the fingers, when, with the right 
hand, the cotton balls may be placed in the vagina with great facility ; 
at first several on the os and around it, and then the whole vagina may 
be packed solidly under the eye of the operator. If Sims's speculum, 
be at hand, it should be used instead of the two fingers to hold back 
the perineum. Or we may vary this according to the process described 
by Dr. Thomas in the American Journal of the Medical Sciences for July, 
1876, page 147. After dilating the vagina, " pieces of cotton, soaked 
in water, pressed and flattened out by the fingers, each about the size 
of a very small biscuit, are pressed into the vaginal cul-de-sac by 
means of the forceps till this is filled. Then other pieces are packed 
firmly around the cervix until only the os is visible ; a smaller pad is 
then pressed firmly against or introduced within the cervical canal, 
and the whole vagina is then filled to its lowest portion." An ordi- 
nary surgeon's roller answers admirably for a plug, and may be intro- 
duced by first inserting one end, and then passing it up in short folds 
until enough has been placed in the vaginal cavity to fill it up com- 
pactly. In most cases, where we desire to leave the patient, the tampon 
should be retained by a compress and "T " bandage. 

When we have reason to anticipate a sudden occurrence of severe 
hemorrhage in our absence, we may instruct the patient or nurse how 
to make and apply a very safe vaginal plug. A sponge, large enough 
to fill the vagina closely, may be prepared by wetting it in a strong so- 
lution of alum, or in a weak solution of subsulphate of iron, passing 
a piece of strong twine or tape through the centre, and then wrapping 
it with tape in an elongated shape to its smallest dimensions. It may 
then be laid aside to dry. When the necessity for its use arises the 
tape is removed, and the sponge thus compressed may be passed with- 
out any resistance entirely into the vagina. It is soon expanded by 
the blood, and the vaginal cavity thoroughly filled. A few of these 
sponges prepared ready for instant use will enable the patient to pre- 
vent any material loss until the practitioner arrives. The plug may 
be removed by the tape or twine whenever desired. The plug may 
be allowed to remain from eighteen to twenty-four hours, when it 
should be withdrawn, and the vagina having been thoroughly cleansed 
with carbolized water, replaced if necessary. 

Curative Treatment. 

The central nervous disorders which cause uterine hemorrhage will, 
when recognized, require the treatment set forth in the various works 
upon these subjects. I need not, therefore, dwell here upon the man- 
agement of the spinal and cerebral inflammations and- irritations, nor 
upon the numerous forms of emotional excitement which lead to 
metrorrhagia. The treatment of the reflex, morbid, nervous influences 



TREATMENT OF MENORRHAGIA. 305 

belongs more particularly to gynecology, and will call for all the in- 
genuity and varied knowledge taught in that branch of practical medi- 
cine. The ovarian derangements, being the more obvious and common 
of these may be noticed first. Our means for replacing and retaining 
in position displaced ovaries are very meagre. The patient must be 
confined to the horizontal position, with the pelvis elevated as much 
as practicable. The knee-chest position is the best, and may often be 
maintained for a considerable part of the twenty-four hours. Generally 
the displacement is accompanied by congestion or inflammation of 
the ovarjr, which increases its size and weight. When this is the case, 
the treatment, in addition to position and quietude, recommended 
during the intermenstrual period, will consist in the use of counter- 
irritants, hip-baths, hot-water vaginal injections, and alteratives, ad- 
ministered internally, or applied externally in the form of ointments 
or per vaginam as suppositories, injections, etc. Among the altera- 
tives, the muriate of ammonia will be found very valuable. When 
there is much debility, the bichloride of mercury, dissolved in the com- 
pound tincture of cinchona, is among the very best. Iodine, iodide of 
potassium, and iodide of iron should also be named as efficient altera- 
tives in these conditions of the ovaries. One derivative measure which 
I desire to mention as especially beneficial in these cases is dry cup- 
ping over the sacrum, often repeated. To be effectual the cups should 
be large and allowed to remain for a long time, say an hour or more. 
When there is much pain in the ovarian regions, suppositories of the 
extract of belladonna and ergot, once or twice daily, will not only re- 
lieve the pain, but will do much towards allaying the inflammation. 

When hemorrhage occurs in a nursing woman, if it is of sufficient 
gravity, the child should be weaned. At the time of the paroxysm, 
if the breasts are tumid and tender, cold may be applied to them to 
relieve both the uterine hemorrhage and the mammary congestion. 
These patients require invigorating measures in connection with the 
local treatment of the breasts. 

The vesical or rectal tenesmus which gives rise to hemorrhage must 
be treated by the remedies found necessary after investigating the cause. 
So also, with diseases of the stomach, bowels, and liver, as well as with 
the effect of cold or of long-continued heat. 

Subinvolution and chronic congestion of the whole uterus require 
a treatment very much alike, the application of such remedies as 
condense the uterine tissues, — ergot, belladonna, quinia, electricity, 
cold injections, compresses, and sitz-baths. When there is no tender- 
ness, ergot will be found a very efficient remedy, if administered for a 
sufficient length of time — several months, for instance. If there be 
considerable tenderness and pain, belladonna and quinia will be best 
adapted to the case. Ergot in some instances induces sensitiveness and 
heat in the pelvic organs, and then it should be used very cautiously. 

20 



306 MENORRHAGIA AND METRORRHAGIA. 

This effect of ergot is especially noticeable when there is chronic local 
peritonitis or cellulitis. If there is a high degree of sensitiveness, a 
mercurial alterative may very properly be given in connection with 
the belladonna and quinia. A good form for administering it is the 
bichloride of mercury dissolved in the compound tincture of cinchona; 
or we may use mercurial inunction, or mercury in suppositories. I 
have not been able to do much good in these cases with iodine in any 
form. If given with iron, as the iodide of iron, it has occasionally a 
good tonic and alterative influence. These conditions of the uterus 
are very obstinate, and require a continuous treatment, oftentimes for 
many months. 

The treatment of endometritis, described elsewhere, consists mainly 
in a persevering continuance of stimulating applications to the dis- 
eased mucous membrane. I do not like the term caustic application, 
for even the strongest remedies used for this purpose are applied so 
sparingly that their effects are little more than strongly stimulative. 
In the light of our present knowledge of the processes of menstrua- 
tion, these remedies, as suggested by Dr. Atthill, should be resorted to 
immediately after the monthly flow has ceased. By common consent 
of the profession, in this country, the treatment of granulations of the 
uterine mucous membrane consists in scraping them off. If the 
mouth of the uterus be sufficiently patent to admit a small-sized curette, 
the scraping may be done effectually without dilatation ; if not, a 
tupelo, or sea-tangle tent, may precede it. 

The curette should be passed over every point in the uterine cavity 
with firmness enough to detach the soft excrescences, and yet there 
should not be force enough employed to wound the natural tissue. Suc- 
cess will generally be announced by the discharge of the soft elongated 
growths. These are sometimes very abundant. The scraping should 
be done during the flow. It is not necessary to wait for a protracted 
paroxysm to pass by. 

Although not curative, the same treatment may be mentioned as 
most efficacious in arresting the hemorrhages resulting from cancerous 
granulations. In a discussion of Dr. Hanks' recent paper, Dr. Peaslee 
gives the very judicious advice not to cut into the sound tissue in the 
process. In cases of malignant fungus, we may often arrest the ten- 
dency to hemorrhage by injecting alcohol, by means of a hypodermic 
syringe, deeply into the substance of the part. This process frequently 
repeated sometimes retards the growth very materially. The tincture 
of the chloride of iron, similarly used will often have the same effect. 

The various conditions which give rise to retardation of the venous 
circulation require to be treated according to the improved methods 
now so well understood by the profession. The displacements of the 
uterus, which are arranged among these conditions, must be corrected 
by the various ingenious appliances designed for this purpose. And 



TREATMENT OF MENORRHAGIA. 307 

this may be done during the time of the preternatural flow with the 
expectation of moderating it at once. 

Dr. T. D. Fitch, of Chicago, has recently proven this last assertion 
in the management of a case occurring in a patient who had just passed 
the menopause. The uterus was retroverted, and all the means re- 
sorted to did not even moderate the metrorrhagia until the organ was 
elevated and retained in position by an appropriate pessary, when in a 
short time the bleeding ceased. After the subsidence of the flow, the 
patient removed the instrument, on account of some slight inconven- 
ience which it gave her, but the flooding began again in a very few 
hours, and continued, notwithstanding repeated efforts to arrest it, until 
the pessary was once more introduced, when the hemorrhage again 
subsided, and did not return. 

The extreme danger from hemorrhage connected with fibrous tumors 
of the uterus is not so often encountered since the profession has be- 
come acquainted with the great influence exerted upon certain condi- 
tions of the unimpregnated uterus by ergot. It is now understood 
that fully seventy-five per cent, of hemorrhagic cases of fibrous tumor 
of the uterus may be rendered free from danger, as far as the hemor- 
rhage is concerned, by an intelligent and persevering use of ergot, and 
that in twenty per cent, the tumors may be removed. In using ergot 
in these cases, the mode of administering it cannot be uniform. Some 
patients cannot take it in any sufficient doses to answer the purpose ; 
some cannot take it in the form of fluid extract, or wine, but can take 
the solid extract in the form of pills ; others can take it in any form . 
When the stomach will not tolerate the ergot, it may be given hypo- 
dermically, or per rectum in suppositories, and I believe that it can be 
made to act efficiently when given in any of these ways. 

Whatever method or form we may adopt in the aaministration of 
ergot, we should give it in sufficient quantities to produce a sensible 
effect by causing contractions and pain, and there is no better rule to 
guide us, so far as I can judge, than to give it in increasing doses 
until that result follows. Twenty minims of the fluid extract, three 
times a day, will sometimes be sufficient, while some patients, on the 
other hand, will require twice or three times as much to produce the 
effect. 

The length of time required to obtain the ultimate effects of the 
ergot in these doses varies as much as the quantity required. The 
tumor will sometimes diminish very rapidly, but generally the decrease 
in size is quite slow. From one month to over a year may be required 
to accomplish a cure when it can be accomplished at all. Ergot is 
sometimes very violent in its action, but by withdrawing it tempor- 
arily, lessening the dose, or combining and alternating it with ano- 
dynes, it may be safely managed. Although I have given it exten- 
sively, and for a long time together, I have not seen anything worse 
than inconvenience arising from its use. 



CHAPTEK XII. 

DYSMENORRHEA. 

This is a general term for painful and difficult menstruation, and 
includes conditions widely different in their nature. In some cases 
no appreciable morbid changes are discoverable in the organs which 
seem to be the seat of pain, either during or between the times of the 
menstrual flow. This condition is called neuralgic dysmenorrhcea. 

It depends upon a general state of the system, which is supposed 
by some to be rheumatic and by others purely neuralgic. It would 
be difficult to define with any accuracy either of these conditions, the 
rheumatic or the neuralgic diathesis, and yet we know enough about 
their manifestations to be able to detect their presence. 

The character of the symptoms of this form of dysmenorrhcea is 
determined by the conditions of the system. 

It generally occurs in patients who are manifestly subjects of one of 
these diatheses, and who in the intervals between the periods experience 
neuralgic symptoms, or symptoms referable to rheumatism. 

These features of the cases are sometimes so marked as to be easily 
detected, while at other times they are not well defined. "Whether 
there is some permanent morbid condition of the nervous apparatus 
of the pelvic organs that is perpetuated from month to month, and 
thus constitutes the disease, or whether in neuralgic patients the vas- 
cular and nervous disturbance of the menstrual period is sufficient to 
excite and localize the morbific energies of this diathesis, we do not 
know. I have been in the habit of teaching the latter. The paroxysm 
of suffering is more irregular with reference to the commencement of 
the flow than in any other form of dysmenorrhcea. More frequently 
than otherwise the pain begins one. two. or even three days before the 
time of the flow, and continues in a subdued degree during a great 
part of the time of the flow It is sharp and paroxysmal, but not 
generally accompanied with tenesmus. The pains do not seem to be 
influenced much by the flow. The intensity of the symptoms vary 
from slight and very tolerable pains in some patients to the greatest 
agony in others. 

This kind of dysmenorrhcea occurs in that class of patients of whom 
it is often said, "They suffer more than any one else from the same 
cause." They are very nervous patients. The seat of the pain is not 
always the same; sometimes it is referred to the uterus exclusively, 
but generally the pain radiates to the ovaries, the back, in the region 
of the genito-spinal centre, and down the limbs. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 309 

Diagnosis. 

A physical examination of the pelvic organs enables us to declare 
that there is none of the morbid conditions we usually find in the 
other forms. This, with the diathetic manifestations, are the only 
means of arriving at definite conclusions. 



'& 



Prognosis. 

This affection, although it is obstinate and resists treatment of almost 
every kind, and is apt to return after it is supposed to be cured, j^et 
the effects of judicious treatment upon it are quite marked. 

Treatment. 

Change of climate, scenery, and modes of living are among the most 
promising remedies. I have known patients to be entirely free from 
dysmenorrhceal paroxysms during a long tour in Europe, and others 
to be relieved by moving from a northern to a southern climate. 
There is probably no better way to produce a decidedly salutary and 
lasting effect upon the nervous system of these patients than to revolu- 
tionize their surroundings by change of climate. A summer residence 
by the seaside, the bathing and exercise connected with it, will often 
suffice to interrupt the recurrence of these paroxysms if not cure the 
disease. 

If we cannot remove the patient from the circumstances under 
which her disease originated, we may do a great deal to get rid of the 
diathesis by outdoor exercise on horseback, or on foot, and if neither 
of these is possible, in a carriage. 

The diet should be regulated with a view to an exalted state of nu- 
trition. Medicines may also be made to exercise a powerful influence 
upon the diathetic condition. 

In cases where we can trace a rheumatic taint we should give med- 
icines with a view to relieve it ; among which are Dewees's tincture of 
guaiac. in drachm doses, three or four times a day, the tincture of ascle- 
pias tuberosa, or viburnum prunifolium. In the more purely neu- 
ralgic cases, tonics containing iron, strychnia, quinine, and phosphorus 
are serviceable. The phosphide of zinc and the oxide of zinc will also 
be found very useful remedies for this general condition. 

The manner of treatment of the paroxysm is also of great importance. 
As we can calculate with some definiteness the time when the par- 
oxysm will come, we may anticipate it with such remedies as will 
produce a strong impression on the nervous system. 

The late Dr. M. B. Wright taught his students that large doses of 
quinine given one or two days before the expected paroxysm, with a 
view to having the patient pass into it in a state of cinch onism, often 
mitigated her suffering very greatly, and sometimes entirely prevented 



310 DYSMENORRHEA. 

it, If, as he supposed, many cases were due to malarial influences 
we might expect great good from this treatment. Arsenic is another 
remedy that will sometimes mitigate the suffering if given so as to 
exert its full influence at the time of the paroxj^sm. To do this its 
administration must be commenced at least a week before the return, 
and be continued from small to increasing doses until characteristic 
effects appear. In giving remedies for the relief of pain during the 
paroxysms we should have in mind that patients afflicted with this 
form of dysmenorrhea are easily fascinated with the effects of anodynes 
and give them up with great reluctance, and that there is therefore 
great danger of making opium-eaters of them. 

I could point out a number of patients who have abused the pre- 
scriptions given them for this purpose to their great sorrow. 

We should feel a proper sense of responsibilty in these cases, use 
anodynes as sparingly as possible, and place them beyond the reach 
of the patient when the urgency' of the symptoms has passed. Chloral, 
chloroform, and morphia are the anodynes upon which we will be 
obliged to rely in the extreme agony of a paroxysm. 

The Inflammatory Form of Dysmenorrhoea. 

In this variety of dysmenorrhoea the condition giving rise to the 
paroxysm is inflammation in some of the pelvic organs, generally the 
uterus, the ovaries, or both. Whether there is a pure ovarian dys- 
menorrhoea of this nature or not, I am not prepared to positively 
assert, but I think it very probable that there is. In most cases of 
inflammatory dysmenorrhoea, however, I believe the morbid condition 
exists in both the ovaries and uterus. In exceptional instances the 
inflammation may be located in the cellular tissue, and perhaps in 
other pelvic structures. 

Symptoms, 

Patients laboring under this form of the affection are generally the 
subjects of intramenstrual symptoms of -sufficient intensity to mark 
the nature of the causing conditions. They are the usual symptoms 
of uterine or ovarian disease. It is in this form that intramenstrual 
paroxysms occur midway between the menstrual periods. These in- 
tramenstrual paroxysms are sometimes very severe, but probably are 
not so intense as those occurring during the periods. 

The paroxysms usually commence some hours, and, occasionally, a 
day or two before the flow, and partially or completely cease as soon 
as the flow is established and becomes free. The pain is generally of 
a somewhat steady aching character, not so intense, but more contin- 
uous than the neuralgic form. The paroxysm is usually attended 
with febrile phenomena. Sometimes there is a sharp attack of fever, 
preceded by chilliness, and accompanied with furred tongue, headache, 



THE INFLAMMATORY FORM OF DYSMENORRHEA. 311 

and pain in the limbs. The pain is not always confined to the pelvis, 
but radiates upward and downward. The paroxysm is usually 
accounted for by supposing that the pain due to the existing inflam- 
mation is very much aggravated by the hyperemia and hypera3sthesia 
attendant upon the occurrence of menstruation. However this may 
be, they are distinguished by this similarity to the pains of inflamma- 
tion. 

Diagnosis. 

A thorough physical examination, for which I will refer the reader 
to the Diagnosis of Uterine Disease, will enable us to discover the lo- 
cality, character, and grade of the morbid process. 

Prognosis. 

The prognosis of this form of dysmenorrhea I believe to be more 
favorable than any of the others, because more amenable to treatment. 
It does not cause that intensity of suffering which we witness in some 
of the other varieties. 

It may not be irrelevant to state here that while we do meet with 
pure examples of neuralgic and inflammatory dysmenorrhea there is 
often an obvious neuralgic element in the inflammatory form — a com- 
plication of the two varieties. Sometimes one of these morbid condi- 
tions predominates, and sometimes the other. 

Treatment. 

For the special treatment of the inflammation as the controlling 
element in this affection I must refer the reader to the methods of 
treatment elsewhere given. The progress of the cure of that element 
will be marked by the subsidence of the intensity of the paroxysms 
until they fail to return. 

In this form we may often anticipate the paroxysms, and allay them 
by appropriate treatment. The patient should be directed to take her 
bed before it comes on, and remain quiet until the paroxysm is over.. 
Particular attention should be directed to her bowels, and it will often 
be best to give her a small dose of a mercurial — two or three grains 
of calomel, and follow it in seven or eight hours by a saline cathartic. 
After this diaphoresis should be encouraged by the acetate of potash,. 
and, as the pains begin, Dover's powder. The anticipatory local treat- 
ment consists in bloodletting by leeches or scarification the day before 
the expected paroxysm. Hot-water injections, continued through the 
attack as often as three or four times in twenty-four hours, hot fomen- 
tations over the hypogastrium, and tepid sitz-baths. These will often 
do away with the necessity of using anodynes. When the pain is not 
relieved by these measures anodynes in sufficient quantities to miti- 
gate it are permissible. 



312 DYSMENORRHEA. 

Membranous Dysmenorrhea. 

The particular feature of this form of dysmenorrhoea is the discharge 
of a membranous cast of the cavity of the uterus. Sometimes the 
membrane comes away without losing its shape or integrity ; very 
much more frequently it is discharged in a broken condition, and ap- 
pears in shreds or large pieces, representing in shape and size the 
anterior or posterior wall of the cavity of the uterus. 

" The microscope shows that the discharges at times consist simply 
of fibrinous clots, which are with difficulty passed through the os 
uteri, when it is very small, as is frequently the case in females who 
have never borne children ; at other times the fibrin is in a fibrillated 
state, inclosing in its reticulum numerous lymph and epithelial cells. 
In other cases there are found irregular shreds, containing capillary 
vessels with embryonic walls, in the midst of connective tissue, infil- 
trated with lymph-cells. There are also frequently seen fragments of 
uterine glands. This is a genuine discharge of exfoliated mucous 
membrane. The mucous membrane may be expelled entire ; this, 
however, is not of frequent occurrence."* 

Numerous theories have been propagated to explain the formation 
of this membrane. It would seem that the ideas prevailing with 
reference to the formation of the deciduous membrane have influ- 
enced the profession in their opinions as to the conditions giving rise 
to this membranous formation. 

In the theory adopted by Dewees, Montgomery, and others, that it 
is a layer of plastic lymph spread upon the uterine wall, we see some- 
thing of the Hunterian explanation of the formation of the decidua. 
In another theory, advanced by Oldham and others, we see the results 
of the researches of Coste, who considers the decidua nothing more 
than the mucous membrane of the uterus, changed by impregnation. 
According to this theory it is the menstrual decidua which does not 
undergo disintegation as completely as in health ; in other words the 
membrane is the result of hypernidation. In the natural condition of 
the uterus the mucous membrane undergoes changes that render it 
suitable to become the nidus for and to embrace and fix the ovum in 
its development. When conception does not take place the disintegra- 
tion of the membrane and the flow are contemporaneous. If the 
membrane is overdeveloped by reason of a preternatural amount of 
connective tissue, then the membrane retains its integrity to a certain 
degree, and instead of flowing out as debris it is expelled as a whole 
or in large shreds. 

I believe with Scanzoni that the uterus in which the formation of 
this membrane occurs is in a state of hyperemia. Sometimes this 

* Cornil and Ranvier's Pathological Histology, translated by Shakespeare and Simes, 
p. 68% 



MEMBRANOUS DYSMENORRHEA. 313 

hyperemia is trophic, and then the membrane will contain capillary 
bloodvessels and utricular glands, while in others it is inflammatory, 
and the discharge will contain fibrinous clots and false or fibrinous 
membrane, inclosing in its reticulum lymph and epithelial cells. 

This view of the subject will enable us to explain the microscopic 
appearances noticed in different cases. Clinical observation will also 
sustain the position that inflammation is the main factor in a portion 
of these cases at least. 

In the cases in which there is trophic hyperemia, the initial or 
actuating condition is probably nervous, and the influence reflected 
through the ovaries, as in the production of normal menstrual conges- 
tion or the hyperemia of pregnancy. 

Symptoms. 

The paroxysm is sometimes ushered in by nausea, vomiting, rapid 
pulse, furred tongue, headache, and increased temperature, and in 
many respects resembles inflammatory dysmenorrhcea ; at other times 
there are no febrile symptoms; but in most cases of membranous 
dysmenorrhoea the stomach sympathizes with the pelvic trouble. 

The pains usually begin after the commencement of the flow and 
continue until the membrane passes. They are at first sharp, and 
dart from the pelvis in every direction, afterward cramping, and 
finally tenesmic or expulsive. The pains have for their object the 
separation and expulsion of the membrane, and subside as soon as 
this is accomplished. 

The more complete the formation of the membrane, the more urgent 
and painful the efforts to get rid of it. The most distressing part of 
the suffering depends upon the effort to overcome the resistance of the 
os uteri to the evacuation of the membrane. 

Without this resistance it is uncertain whether there would be much 
pain, as I have known two cases in which the membrane was repeat- 
edl} 7 evacuated without pain. In both cases the internal os uteri was 
patulous. I have never seen the membrane expelled by parous women. 

Diagnosis. 

This depends upon the discovery of the membrane either in pieces 
or as a whole. While my observation has not been sufficiently ex- 
tensive to enable me to establish a rule even for my own guidance, I 
believe it will be found that in cases attended with febrile symptoms 
the membrane will be of a plasmic character wholly, and that in 
those unattended by these symptoms the membrane will partake more 
of the deciduous character. 

The prognosis of membranous dysmenorrhcea is not very encourag- 
ing, as it is very difficult to overcome the disposition to the formation 
of the membrane. 



314 DYSMENORRHCEA. 

Treatment. 

The paroxysm of membranous dysmenorrhcea, especially the more 
febrile form, should be treated with a view to removing the obstruc- 
tion. The cervix should be dilated by Hunter's or some other dilator 
as soon as the pains become severe and expulsive in character : this 
will generally very materially shorten the duration, as it facilitates the 
discharge of the membrane. In connection with the dilation, or with- 
out, an efficient dose of ergot will sometimes aid the process of expul- 
sion very materially. 

Sometimes we may prevent or mitigate the severity of a paroxysm 
by using a fasciculus of slippery-elm tents a day or two before it 
occurs, especially in the febrile form. 

If the paroxysm is attended with vomiting and fever, we should 
anticipate it by giving a cathartic the day before its occurrence and 
administer large doses of quinine. 

The administration of ergot between the paroxysms in the trophic 
variety will aid very materially in overcoming the hypersemic condi- 
tion of the uterus, and produce a favorable influence upon the nerve- 
centres that preside over the process of ovulation. Mercurial and 
iodine alteratives should take its place in the inflammatory variety. 
The ammoniated tincture of guaiac. may be given with great propriety 
when a rheumatic diathesis is suspected. The local treatment of the 
two is very nearly the same, viz., dilatation and applications to the 
mucous membrane of the cavity of the body of the uterus, as in cases 
of chronic inflammation and congestion of that organ. 

Obstructive Dysmenorrhcea. 

The clinical study of dysmenorrhcea will force upon the observer 
the conviction that, in the majority of cases, this symptom is the re- 
sult of uterine contractions, and that the contractions are efforts made 
by the uterus to expel its contents. 

As I have already shown, this is the case in the membranous variety, 
the real cause of the expulsive pains being obstruction, not because 
there is contraction of the os uteri or cervical canal, but because the 
substance expelled required more room for its passage than was 
afforded by the os of normal size. 

In the inflammatory variety the same kind of pains are often no- 
ticed. Doubtless the cause of the expulsive efforts in this variety is 
the temporary stenosis of the internal os uteri, caused by the tumefac- 
tion of the mucous membrane at that point at the time of the men- 
strual congestion. This explanation presupposes endometritis with 
the greatest intensity of the inflammation at that point. Between the 
menstrual periods the tumefaction subsides, and the os presents no 
evidence of stenosis. This is one form of temporary stenosis causing 



OBSTRUCTIVE DYSMENORRHEA. 315 

dysmenorrhoea. Another is spasm of the circular fibres surrounding 
the internal os uteri at the time of menstruation. 

We are prepared to understand how this may take place in patients 
of irritable fibre, when we remember the hyperesthesia that accom- 
panies chronic inflammation of the uterus and the congestion preced- 
ing the eruption of the menstrual discharge. 

I have no doubt that the cause of temporary stenosis, even in the 
inflammatory form, is often spasmodic closure, as blepharospasm is 
caused by conjunctival inflammation. 

I think this spasmodic action is much more likely to occur in the 
inflammatory than in the neuralgic variety. There is one condition 
in which the expulsive pains of dysmenorrhoea manifest themselves 
with great severity where no stenosis exists. When there is a great 
degree of retroversion or retroflexion the cavity of the body is lower 
than the internal os uteri. 

In such cases the extra vasated blood, instead of flowing toward the 
mouth of the uterus, gravitates into the fundal portion of the cavity 
and there accumulates until its presence excites uterine contractions. 

Fig. 191. 




Strong Retroflexion favoring Gravitation to the Fundus. 

It would seem from these considerations that much of the suffering 
connected with retroflexion, and even anteflexion, with or without 
stenosis, is fairly attributable to the gravitation of the blood into in- 
stead of out of the uterus. 

I would call attention to the figure of retroflexion, here introduced 
to demonstrate this proposition : Would it be possible, even if there 
was no stenosis, for the blood to flow out ,of a uterus in the position 
there represented ? And would not the accumulation of the blood in 
the dependent cavity, and perhaps coagulating there, as certainly pro- 
duce efforts at expulsion as any other foreign body ? Since my atten- 
tion has been directed especially to this item, in the pathology of dys- 
menorrhoea, I have been convinced that too much importance has been 
attached to simple stenosis. 



316 DYSMEXOEEHCEA. 

Nearly all cases of obstructive dysmenorrhea are associated with 
displacement or flexional deformity of the uterus. "When gravity fa- 
vors the outflow of the menstrual blood it requires only a very small 
passage through which to escape, I have repeatedly examined patients, 
in whom the external os uteri was not larger than a pinhole, whose 
menstrual flow was easy and copious. While thus expressing myself 
with reference to the importance of malposition and flexional deform- 
itv of the uterus as offering a sufficient impediment to the discharge 
of the blood to induce the most distressing form of dysmenorrhcea, I 
would not ignore stenosis as one of the causes of it. 

Any cause that will give rise to retention of the menstrual flow will 
cause uterine contractions and pain. A typical case, in which dys- 
menorrhceal symptoms from forcible retention of the menstrual fluid 
are manifested, is congenital occlusion of some portion of the genital 
canal. If the obstruction is at the orifice of the vagina, the pains will 
not be of this character until the vagina is filled and a portion of the 
blood is retained in the uterus ; but if the occlusion is at the uterus, 
the symptoms will begin with the first menstrual effort. To witness 
a case of this kind will convince the observer that obstruction to the 
flow will give rise to dysmenorrhoeal symptoms. If there is a great 
degree of stenosis in a part of the genital canal symptoms of a similar 
character will occur. 

Symptoms. 

The main symptom of obstructive or retentive dysmenorrhcea is ex- 
cruciating pain of an expulsive character. The pains are compared 
to colic, and the term uterine colic is quite appropriate. 

They generally come on before the commencement of the flow, and 
continue until the discharge is well established, when they gradually 
subside, and the flow continues from that time on without pain. In 
many instances the great congestion accompanying the effort at dis- 
charge, causing a sort of erection of the uterus, not only overcomes 
the stenosis, but it temporarily, to a great extent, corrects the position 
or deformity ; without this correction the relief would not be complete. 
If the attendant will take the trouble to examine patients carefully 
during the flow — which by the way is very seldom done — he can easily 
convince himself of the truth of this statement. 

Diagnosis. 

The diagnosis may be established by physical examination. Ob- 
struction of the vaginal orifice by the hymen, morbid adhesions, or 
congenital deformity may be detected by occular, digital, and instru- 
mental examination with the sound during the presence of the symp- 
toms. Malposition or flexions will be detected by physical examina- 
tion. 



OBSTRUCTIVE DYSMENORRHEA. 317 

Prognosis. 

Like the other forms of dysmenorrhea, the obstructive variety is 
apt to be very obstinate and difficult to manage satisfactorily ; but as 
the corrective treatment is almost wholly mechanical or surgical, we 
may hope for good results. 

Treatment. 

In cases where there is retroflexion with dependent fundus, the first 
and most important corrective measure is to elevate the organ so that 
the blood will flow into the cervix, and thus escape from the os uteri. 

This may be done before or at the time of the paroxysm. If we see 
the patient for the first time during a paroxysm, we should place her 
in the knee-chest position, and lift the fundus uteri up with one finger. 

Fig. 192. 




Retroflexed Uterus with the Fundus raised by a Pessary. 

By this means we straighten out the cervix, and thus dilate the con- 
tractions and give the blood an inclined plane over which to flow and 
escape. 

This I am assured from repeated observation will often relieve a 
paroxysm. If this is not sufficient, with the patient still in the genu- 
pectoral position, we should introduce a sound to the fundus. In some 
cases elevating the womb, with or without the introduction of the 
sound, will relieve the patient for a few hours only ; but if the pain 
returns, it may be relieved in the same way until the paroxysm sub- 
sides. Between the paroxysms a suitable retroversion pessary should 
be worn, and, if properly placed and watched, will go a great way to- 
ward effecting a cure. 

When there is stenosis, we may often relieve the paroxysm by dilat- 
ing the contracted point with a slippery-elm tent. 

There are two special methods of relieving stenosis, viz. : 1. By in- 



318 DYSMENORRHEA. 

cision. 2d. By dilatation or stretching the parts, with instruments 
made for the purpose, and tents. 

J. Marion Sims, in his work on Uterine Surgery, propounds the fol- 
lowing opinions as to the causes of dysmenorrhcea, and bases his 
treatment on them. He says (page 142) : 

"It (dysmenorrhcea) is only a symptom of disease, which may be caused by inflam- 
mation of the cervical mucous membrane, retroflexion, anteflexion, tibroid tumor in 
one wall of the uterus or the other, contraction of the os externum, flexures of the 
canal of the cervix, either acute or greatly curved, either at the os internum, at the 
insertion of the vagina, or extending throughout the whole length of the canal, all of 
which are but so many mechanical causes of obstruction which must be recognized 
and remedied if we expect to cure the dysmenorrhcea." 

The following table is on page 132 : 

os was normal in but ... 6 

os was contracted in . . .90 

Of 100 cases of painful menstruation, . . . . - cervix was flexed in ... 61 

congested in 7 

there were polypi in ... 2 

f os was normal in .... 

os was contracted in ... 26 

Of 29 cases of excessively painful menstruation, . -j cervix was flexed in ... 23 

I had polypi in 2 

[ was congested in 1 

This tabular testimony of 129 cases is a strong argument in favor of 
Dr. Sims's theory, that dysmenorrhcea is almost always caused by 
obstruction. 

As I have given the opinion of Dr. Sims as to the causes of dysmen- 
orrhcea, I cannot complete this article without giving the reader an 
idea of the mode of treatment found most successful by him, viz., that 
of dilating and straightening the canal of the cervix. He exposes the 
mouth of the uterus by placing the patient in the same position, and 
using the same instrument as 'for vesico-vaginal fistula. With a 
tenaculum he seizes and firmly holds the cervix, and draws it into the 
most convenient position. If the cervix is not flexed but merely 
narrow, he introduces one blade of the scissors into the canal of the 
cervix far enough to divide it on one side up to the junction with the 
vagina, and then closes them. The other side of the cervix is divided 
to the same extent in like manner, then, by means of the knife repre- 
sented in figure, he divides the cervix up as high as the internal os. 

If the cervix is flexed, the lip of the uterus on the convex side is 
divided to the same height, and then the cervix opened with the knife. 
In this way the cervical canal is rendered rectilinear. 

This is represented by Fig. 195, taken from page 169 of Dr. Sims's 
work on Uterine Surgery. It shows the posterior lip already divided 



OBSTRUCTIVE DYSMENORRHEA. 



319 



by the scissors, the tenaculum fastened into the anterior lip, and the 
knife being inserted as high as necessary : 

"The representation in the cnt is taken from the perfected instrument made by 
Wade & Ford, of New York City. To their ingenuity is due the application of the 
principle. The representation is half the size of the instrument, but the blade at full 
size is out of proportion, as it should be represented both longer and narrower." 

Fig. 193. 




Fig. 193 represents the Operation for Dividing the Straight Cervix when too narrow. The dark 
part is the portion cut. On one side the knife is shown in the act of dividing the tissues. This 
is Dr. Sims's plan. 

After having thus completed the operation Dr. Sims places in the 
wound of the lip of the cervix some cotton saturated with glycerin, 




Emmet's Knife for Dividing the Cervix. From a cut in the June number, 1864, New 
York Journal of Medicine. 

and then proceeds to fill the vagina with cotton to guard against 
hemorrhage, which he regards as always imminent. If there be but 



320 



DYSMENORKHCEA. 



slight bleeding, it is not necessary to use more cotton than will keep 
the dressing in place. The patient should keep the recumbent post- 
ure for several days. The cotton in the vagina may be removed in 
twent} T -four hours after the operation; that in the wound remains 
from two to three days. Dr. Emmet recommends that the sound be 

Fig. 195. 




passed through the cervix every other day until the discharge ceases 
to prevent the parts from adhering. The sound need not be used for 
this purpose until the tampon is dispensed with. 

The following are the conclusions in practice of the late Dr. E. R. 
Peaslee :* 

" From the preceding facts I deduce the following conclusions : 

" I. The deep incision of the cervix throughout, the complete bilateral discission of 
the vaginal portion with deep incision above, are alike frequently attended by certain 
immediate dangers, and not seldom productive of certain serious remote consequences, 
viz., profuse and sometimes fatal hemorrhage, pelvic cellulitis, septic peritonitis 
(usually fatal), sterility, if not previously existing, and a tendency to miscarriage. 

" II. Those risks and effects are all due to the extensive division of the walls of the 
cervix, and to the consequent enlargement of the cervical canal ; and the sole com- 
pensation for all of them which can be calculated upon is the relief, and very often 
the cure, of stenotic dysmenorrhea. 

" It therefore becomes a question of very great practical importance whether the 
amount of cutting may not be so far diminished as to avoid all these risks, and at the 
same time be sufficient for the cure of stenotic sterility and dysmenorrhcea. But another 
inquiry antecedent to this is, how large a calibre of the cervical canal is actually re- 
quired for the relief of these two conditions; and a reply sufficiently definite for all 
practical purposes is not so difficult as might appear. 

" In the imparous woman, the narrowest point of the cervical canal, viz., the internal 
os, is, when opened by the passage of the menstrual fluid, an ellipse, whose conjugate 
and transverse diameters average respectively one-sixth and one-eighth of an inch ; 



A paper read before the New York Academy of Medicine, 1876. 



peaslee's method. 321 

its area corresponding very nearly* with that of a circle one-seventh of an inch in 
diameter. The external os, also elliptical when moderately dilated, has diameters 
averaging one-fourth and one-sixth of an inch. It thus has an area exactly twice that 
of the internal os, and equalling that of a circle one-fifth inch in diameter.f The 
larger size of the external os doubtless has a special reference to conception, and favors 
the entrance of the spermatic fluid into the cervical canal. It has no special influence 
against dysmenorrhea, since the menstrual fluid, after having passed through the in- 
ternal os into the cervical canal, would pass just as easily from the latter through an 
opening of the same dimensions into the vagina. Hence, we not very seldom see im- 
parous women with the external os no larger than a ' pin-hole,' and who, neverthe- 
less, do not suffer from dysmenorrhea, though, as a rule, they are sterile. But if the 
lining membrane of the canal becomes thicker from congestion, or some other cause, 
such patients suffer at once from stenosis at the external os. 

" In the pai-ous woman, the size of the external os varies within quite extensive 
limits, since it is exposed to so many of the accidents of parturition, while the internal 
os is more nearly uniform. 

" I have deemed it desirable to ascertain the lowest average diameter of the two ora 
uteri in parous women, who are neither sterile nor have dysmenorrhea, as a rational 
standard for determining the extent of incision actually required for the removal of 
these two conditions when stenotic. And, after a good deal of observation in this 
direction, I find that the inner os presents nearly twice the area of that of the im- 
parous woman ; in the majority of cases admitting a sound one-fifth of an inch in 
diameter, though, in a large minority, one from one-fifth to one-sixth of an inch only 
can be easily passed. I therefore regard a diameter of one- fifth of an inch as ample 
for the removal of sterility and dysmenorrhea. I find the external os admits a dilator 
one fifth of an inch in diameter and upward — in some cases as high as one-fourth or 
even three-tenths of an inch — but, as a rule, I think one-fourth of an inch sufficient 
for the purpose. It is of course to be understood that no narrowing of the canal exists 
between the two ora. Since, however, there may be some degree of stenosis for the 
menstrual fluid, while not for the sound, it is sometimes judicious (and especially if 
congestion of the cervical lining membrane coexists) to increase the dimensions just 
named, by the use of a dilator of the next larger size. I do not assert that the preced- 
ing dimensions are always required in the treatment of stenotic sterility and dysmen- 
orrhea, for they are not, nor that they are never to be exceeded, but that in almost all 
cases they will be found sufficient. 

"Should this precise specification of dimensions seem too minute for practical pur- 
poses, we must remember that dimension cannot here have a less important relation 
to function than elsewhere; and that enlarging the internal os to the diameter of half 
an inch, as is often done by the deep incision, is, as has been seen, like permanently di- 
lating the urethra (if it could be done) to the size of the small intestine. And the im- 
portance of making an incision of the internal os, with a precise intention and a pre- 
cise knowledge of the mode of accomplishing what is intended, may be understood 
when I state that if the circle representing its area in the imparous woman be increased 
equivalently to surrounding it by a ring only one thirty-fifth of an inch wide, its area 
is increased as forty-nine to twenty-five, or almost exactly double. Or, if an incision 
be made on each side of it to the extent of half a line (one twenty-fourth of an inch), 
and it then be dilated to a circle, it is increased two and a half times. And if the cut 
should extend one line to the right and the left, or the added ring were one-twelfth of 
an inch wide, the area would be increased more than four times and a half. This last 

* The circle is smaller than the ellipse, in the proportion of 144 to 147. 
f Circle to ellipse as 72 to 75. 

21 



322 DYSMENORRHEA. 

increase is far more, in my experience, than is ever required in stenotic sterility and 
dysmenorrhea. 

Superficial Trachelotomy — My own Operation. 

" III. Desiring to restrict the operation of trachelotomy in the treatment of stenotic 
sterility and dysmenorrhea within the limits actually required, I, some ten years ago, 
devised and brought before the New York Obstetrical Society* a series of five steel 
cervical dilators, to be used instead of incision, where the stenosis is slight and the 
cervix is normally soft and pliable. These, in shape and size, have a precise refer- 
ence to the dimensions of the cervical canal, and especially of the two ora uteri, as 
already specified ; and each is guarded by a bulb, so as to project through the internal 
os into the uterine cavity only about one-quarter of an inch. 

" But finding that almost all cases of stenosis of the cervical canal are relieved more 
promptly, more permanently, and also with less pain, by incision, or this together with 
dilatation, than by any form of dilatation alone ; I next endeavored to restrict the extent 
of the incision within the absolutely necessary limits, having determined them ap- 
proximately by the preceding facts and calculations. To this end I devised a new 
method, and an instrument for executing it, which I also laid before the New York 
Obstetrical Society about eight years since ; but the former was so simple, bloodless, 
and unpretending, in comparison with the procedures of Simpson and Sims, that it 
excited but little interest. Meanwhile, however, it has been sufficiently tested, I 
think, by myself and my pupils in different parts of the country, to entitle it to a more 
general notice. 

" Since the superficial incision, as suggested by myself, has for its direct object 
merely the removal of stenosis of the cervical canal, and is therefore proposed for the 
treatment of stenotic dysmenorrhea and sterility only, it is previously to be decided 
whether stenosis actually exists. And the following propositions will aid in settling 
this question, it being understood that the exploration is to be made at least four days 
after, and at least three days before, the catamenial flow. 

A. Respecting Stenosis of the Internal Os. 

"1. If a sound one-fifth of an inch in diameter passes easily through the cervical 
canal, there is no stenosis at the internal os, and no incision is there required. This 
is the size, therefore, of my large sound. 

" 2. If a sound one-sixth of an inch in diameter be easily passed, as above, there is 
no absolute, though there may be relative stenosis of the internal os ; i.e., there may 
be stenosis for the passage of a fluid, though not of the sound ; and an incision to make 
it one-fifth of an inch may be required, but not unless the symptoms indicate it. 

"3. If the sound easily passed be but one-seventh of an inch in diameter, and there 
are no symptoms of stenosis, no incision of the internal os is required. This is the 
normal size in the imparons woman, and the average size of Simpson's sound. 

" 4. If a sound but one-eighth of an inch in diameter cannot be passed through the 
internal os, there is either stenosis, or, what is very much more probable, one of the 
flexions. Prove, therefore, that there is no flexion in this and every case in which a 
sound of any size does not traverse the internal os before operating for stenosis. I 
consider an internal os of one-eighth of an inch or less to be stenotic. Chrobak's 
highest limit for stenosis of the internal os is one-tenth of an inch (two and a half 
millimeters). 



Also described in the New York Medical Journal, July, 1870, p. 478. 



PEASLEE S METHOD. 



323 



B. Respecting Stenosis of the External Os. 

"5. On the other hand, there is no stenosis of the external os if a sound one-fifth of 
an inch in diameter easily traverses it. If there be congestion of the lining membrane, 
however, there may be stenosis, practically, in respect to conception ; and the opera- 
tion somewhat enlarging it (to one-quarter of an inch or more) may be required. 

" 6. If the external os will not easily admit a sound one-sixth of an inch in 
diameter, there is probably stenosis in respect to conception, and the operation is re- 
quired. If not more than one-seventh of an inch, the operation will also probably be 
required for dysmenorrhea. 

" 7. In case of operation, the whole cervical canal must be made still to retain the 
normal fusiform shape as far as possible. 

" I. My method consists in incising the internal os, if the stenosis exists at that part, — 
and the external, if at the latter, — to such an extent as to give to each its precise 
average dimensions in the parous woman, neither more nor less, and, of course, also 
overcoming any other point of stenosis existing anywhere else in the cervical canal. 
In cases complicated with congestion, however, I have shown that a slightly larger 
opening may be required, and, therefore, that the limits may extend beyond one-fifth 
of an inch to nearly a quarter of an inch in the case of the internal os, and to three- 
tenths of an inch, and possibly more, of the external. 

" I do not, therefore, incise the internal or the external os to a given depth in all 
cases, but, taking them as I find them, cut just enough to give them their average 
normal size in the parous uterus. This is seldom one-half of a line and often not more 
than one-third of aline for the internal os, and not more than a line for the external. 
But, of course, there is far more variation in the latter. If the internal os admits a 

Fig. 196. 




Dr. Peaslee's Metrotome, half-size. 

sound of but one- eighth of an inch in diameter, a cut on each side of nearly half a line 
(but three-eightieths of an inch) is required ; and if but one-tenth of an inch in 
diameter, it must be one-twentieth of an inch deep on each side. The incisions are of 
precisely the same depth on each of the two sides. 

" Since the lining membrane at the internal os is at most one twenty -fifth of an inch 
thick, it is seen that I generally do not cut nearly through it. Indeed, when the os is 
but one-eighth of an inch wide, I cut almost through the membrane; and when one- 
tenth of an inch, I divide it and one-hundredth of an inch of the tissue beneath it.* 

" II. The instrument devised to secure this effect consists of a flattened tube, con- 
taining a blade. The former is eight inches long and seven-sixteenths of an inch 
wide, except its terminal one inch and three-quarters, which has a width of but one- 
eighth of an inch, as shown in Fig. 196. This portion is made curved by some in- 
strument makers, which is not an improvement. The blade is of such a width as to 
slide accurately within the tube, having a nut and a screw attached to its proximal 
extremity to gauge the extent of its passage into the cervical canal, and a blunt point 



* The details of all the preceding calculations are properly omitted here, as a slight 
acquaintance with mathematics will enable the reader to verify them. 



324 DYSMENORRHEA. 

and lateral cutting edges for an inch and five-eighths at the distal end. There are two 
blades for each instrument, the cutting portion of one being a quarter of an inch wide, 
and of the other three-sixteenths of an inch. If the stenosis is confined to the internal 
os, the narrower blade alone is used. If both ora are contracted, the wider instrument 
is passed through the external os, and the other blade then introduced and the inner 
os incised by it; and in cases of decided congestion, the wider blade alone is sometimes 
used for both ora. In this case, a sound one-fifth of an inch in diameter is easily 
passed through the inner os, while, if the smaller blade had been used, considerable 
force would be required to carry it through. 

" In hospital practice I place the patient upon the side, use the duck-bill speculum, 
hold the cervix by means of a uterine tenaculum, pass the tube into the canal up to 
the shoulder, and, therefore, one-quarter of an inch into the uterine cavity through 
the internal os, when the blade, previously gauged, is introduced into the tube and 
carried up the cervical canal as far as is required to overcome the stenosis. My large 
sound (No. 10, American scale), or, still better, the conical dilator of the proper size, 
is then passed up the canal, and the operation is completed. In private practice I 
generally place the patient on the back, and pass the tube into the cervical canal pre- 
cisely as I would Simpson's sound, and then pass the blade through it, as just 
described. 

"If the external os is too narrow for the admission of the extremity of my instru- 
ment, it may be enlarged by the introduction — generally one-eighth to one-quarter of an 
inch is far enough — of a narrow-pointed bistoury. I have not found the internal os 
too narrow to receive it, except in cases of flexion, or previous traumatic injury of the 
cervix. 

" The changes in the whole uterine cavity from this operation are shown by Fig. 
198. Respecting its dangers I have but little to communicate. The hemorrhage 
following it seldom exceeds one or two drachms, and never requires any special atten- 
tion. The pain is very slight and momentary, and no anaesthetic is ever required. 
The medullary structure of the cervix never being cut into, pelvic cellulitis and peri- 
tonitis do not ensue. The only exceptions to this statement in nearly three hundred 
cases are : one case in private practice, in which some febrile reaction and uterine 
tenderness ensued, which subsided entirely, without cellulitis, in four days ; and two 
cases, in the Woman's Hospital, of slight cellulitis. But both the latter were patients 
who were known to have had cellulitis a short time previously, and 1 was obliged, by 
some peculiar circumstances, to operate sooner than I otherwise would have done. 
The final results were precisely as desired in each of these three cases. Otherwise I have 
never had any unpleasant symptoms follow the operation; and the only precautions 
taken are to keep the patient two days, and sometimes three days, in bed, and not 
allow her to walk out under a week. I use the dilator every second day after the 
operation for a week, and two or three times more once a week. I have very often 
performed the operation at my office on residents of the city, and sent the patient 
home to bed after half an hour's rest, and have never had to regret it. I decline to 
operate within four days after or six days before the catamenial period. 

"I claim for the method just described the following recommendations in the treat- 
ment of stenotic sterility and dysmenorrhea. 

" I. It aims to restore the normal dimensions as existing in the parous woman 
throughout the cervical canal, nothing more and nothing less, unless where a slight 
exaggeration of size is required on account of coexisting congestion. 

"II. It effects this object definitely and with certainty, and with incisions exactly 
symmetrical, or equal on the two sides. 

"III. It gives no danger from hemorrhage, since the arteries nearest the internal 
os, if that is to be divided, are never reached, and the whole thickness of the lining 



PEASLEE S METHOD. 



325 



membrane even is generally not divided ; and there are no arteries within the portion 
divided at the external os. 

"IV. There is no dangth- of pelvic cellulitis, except in those patients in whom the 
least operative interference with the cervix, or the use of the sound or of a sponge- 
tent, will produce it. I consider the operation less dangerous in this respect than the 
last mentioned. 

Fig. 197. Fig. 198. 





Normal Uterine Cavity. 
Fig. 199. 



! \ I 1 

Ditto, as Modified by Peaslee's Method. 



Fig. 200. 




Uterine Cavity after Sims's Operation. 



Ditto, after Simpson's Operation. 



" V. There is no danger of septic peritonitis, since the medullary substance is not 
reached by the incision. 

"VI. It does not produce sterility or tendency to abortion by mutilating the cervical 
canal. The changes it produces in the latter, as compared with those from the opera- 
tions of Simpson and Sims, are shown by Figs. 197, 198, 199, and 200. 



326 DYSMENORRHEA. 

" VIIL It removes stenosis perfectly, and in most cases permanently, since there is 
very little tendency to closure of the slight incision made. I have had to repeat the 
operation only twice in my practice, except in cases in which there was cicatricial 
tissue to be divided, as after imperfect and partial closure following rupture of the 
cervix in parturition, or ensuing after Simpson's or Sims's operations. Here the opera- 
tion will usually have to be repeated in a year or two, unless pregnancy should occur, 
an event not to be expected in such cases, as we have seen. 

"Finally, then, since my experience has shown that a diameter of one-fifth of an 
inch for the internal os, and of one-quarter to three-tenths of an inch for the external 
os, is sufficient in the treatment of stenotic sterility and dysmenorrhea, I suggest the 
disuse of Simpson's and Sims's operation in the treatment of these conditions, and the 
substitution of a milder, safer and more efficacious method, of which, perhaps, my 
own is, however, only the forerunner. At least, further experience in the line I have 
indicated will doubtless afford still more accurate conclusions." 

Dilatation. 

Dilatation is a very effective means of overcoming uterine stenosis, 
when either simple or complicated with flexions or displacements, 
when property done. It is certainly safer, and I believe more effectual 
in most cases than any method of cutting. Dilatation may be accom- 
plished by repeated efforts, continued at intervals for several weeks or 
months, or at one sitting. According to the first plan, dilatation is 
effected once a week or oftener until the cervical cavity is sufficiently 
patent and so remains. This method has the advantage that it is not 
attended with much pain, nor followed by serious inconvenience of 
any kind. Indeed, with reasonable regard to the force used, there will 
be no danger in doing it in the office and permitting the patient to 
return home. In all cases, however, where moderate but decided 
dilatation is done, the patient should lie upon a lounge or bed until 
all pain and uneasiness have subsided. There is no doubt but that 
this trifling operation had better be done at the home of the patient, 
Tents, hard rubber or steel sounds may be used for this purpose. Of 
the tents I would recommend the slipper}' elm as being quite efficient 
and painless, and I know of no other tent now in use attended with 
the same immunity. The sponge, sea-tangle, or tupelo tents are fraught 
with much danger, especially when it becomes necessary to repeat 
their employment. The elm tent has the advantage of great flexibil- 
ity as compared with the others. (See description and mode of using, 
Chapter IV., Figs. 96 and 97.) The well-known success of Dr. Mackin- 
tosh with graduated steel sounds, as practiced fifty years ago, if noth- 
ing more were said of them, has established their reputation. To 
effect sudden dilatation these instruments may be used quite advan- 
tageously. To make sudden dilatation safe with these or any other 
instruments, the preparation and subsequent treatment should be the 
same as for any other important surgical operation, and no means left 
undone to prevent septic or inflammatory consequences. 

The operation of dilating the cervical canal with bladed instruments 



DILATATION. 327 

is a simple mechanical procedure, easily executed, and on the whole 
more satisfactory than with sounds, tents, or bougies, except the slip- 
pery elm tents. There are a large number of instruments for this 
purpose, mostly two bladed, although some have three or more blades. 
Hunter's and Goodell's instruments are both excellent. The main 
difference between them is that Goodell's has blades with corrugated 
surfaces to keep them from slipping out while being separated. Dr. 
Goodell's is made in two sizes, the small one for cases in which mod- 
erate dilatation is required, and to precede the larger one when the 
passage is too small to admit it. For slow dilatation these instru- 
ments may be used through the common speculum three or four 
times a month, and the cervix dilated to one-fourth of an inch for the 
first few times, and afterwards half an inch. Each sitting should last 
ten minutes or more with the administration of an anodyne when 
there is pain, and the precautions of quietude always for at least half 
an hour after. When the blades of the instruments are passed beyond 
the internal os uteri, and the manipulations continued sufficiently 



Fig. 201. 




Goodell's Dilator. 



long, success is likely to follow. The operation for sudden and exten- 
sive dilatation is, of course, a much shorter way to the object than 
this, and while more hazardous, is very efficacious. 

After being etherized, the patient should be placed on her back on 
a table with the perineum projecting slightly over the end of it. The 
vagina should be dilated by Simon's instruments, and the cervix 
seized by a light vulsell, drawn slightly down toward the vulva and 
held firmly. This traction generally reduces the cervical flexion to 
such a degree as to permit the blades of the instruments to pass the 
contracted part and enter the cavity of the body. After this com- 
plete entrance is manifest the blades should be slowly separated until 
the required amount of dilatation is effected. The instruments should 
be allowed to remain in this position for ten or fifteen minutes. They 
should then be introduced with the curve of the blades reversed, 
and also turned half around, and similarly expanded. The extent 
to which this distension should be carried will depend to a great 



328 DYSMENORRHEA. 

extent upon the severity of the symptoms of obstruction. Dr. Goodell 
advises from three-quarters to one and a half inches. I think it 
ought also to depend on the condition of the cervix — very small 
pointed cervices dilate badly, and may be torn by extensive stretch- 
ing, while in patients who have had children, there is not so much 
difficulty. The time for operating is soon after the menstrual period 
has passed. After the operation the patient should be put to bed, and 
carefully guarded against attacks of pelvic inflammation or other evil 
consequences. 

Another means of dilating and straightening the uterus to overcome 
the stenosis caused by flexion, is the stem pessary. The value of this 
instrument has been the subject of much discussion ; some gynecolo- 
gists condemning it altogether, and giving potent arguments against 
it, while others speak of it as the best of all means and, where prop- 
erly used, entirely harmless. There is no question that the difference 
in estimating its worth depends largely upon the manner of managing 
it. The danger and not the efficiency of the instrument is the point 
in the dispute. Winckel* puts the subject in its proper light when he 
says b}^ careful preparation, and the proper selection of cases, the use 
of the intrauterine stem is free from danger, while from carelessness on 
the part of the physician or the patient it may give rise to months of 
suffering. He considers the evil consequences to be " hemorrhages, 
colicky pains, parametric exudation, and occasionally peritonitis," 
and he might have added metritis. In fifty cases in his own practice 
he has met with but two cases of parametritis. Prof. A. Reeves 
Jackson read a paper upon this subject before the Chicago Medical 
Society, June 7, 1886, giving the results of this treatment in sixty-four 
cases. Of the entire number, a cure of the flexion followed in forty, 
four were improved and relieved of dysmenorrhea which before had 
been constant. In twenty the result was unknown. Dr. Jackson 
prefers Chambers's bifurcated vulcanized instrument. The short 
glass stem recommended by Dr. Chamberlin and Prof. Thomas, of 
New York, is a very neat and effective one, and will usually be toler- 
ated as easily as any other. 

The patient should be prepared for the use of the stem by remov- 
ing inflammation when present, by hot water douches and glycerine 
cotton tampons for a sufficient time. Immediately prior to introduc- 
ing the instrument the rectum should be emptied, and the vagina and 
vulva disinfected with carbolized water. 

To adapt the instrument, the patient should be placed in Sims's 
position, the Vagina dilated with Sims's speculum, and the uterus 
drawn down and fixed by a small vulsell forceps. This will some- 
what reduce the flexion, when we may pass the sound and measure 

* Lehrbuch der Frauen Krankheiten. Leipzig, 1886, p. 331. 



DILATATION. 329 

the length and size of the uterine cavity. A stem should be selected 
that is nearly half an inch shorter than the measurement, and with 
the dressing forceps placed in position. To keep the instrument from 
being expelled, a tampon of borated cotton should be placed against 
it, and left in that position for twenty-four hours. The tampon 
should then be removed by placing the patient under the same con- 
ditions with reference to position as for the introduction. After that 
the stem will generally remain in place. If it does not the tampon 
may be used again. The patient ought to remain in bed for several 
hours after the instrument has been placed. 



CHAPTER XIII. 

METATITHMEN1A (Mtran^/u^r): OR, MISPLACED MENSTRUATION. 
PERIUTERINE HEMATOCELE. 

The accident to which I apply the above terms is an effusion of 
blood in tissues around and above the uterus, the effusion being some- 
times very extensive, at others limited to a small space. The effusion 
may take place in the vaginal wall, between the vagina and rectum, 
tearing up their connecting tissue, or in the posterior wall of the 
uterus, beneath the peritoneum, or between the peritoneal layers of 
the broad ligament beside the uterus, or in the peritoneal cavity. 
The mode of the accident varies somewhat, owing to the locality in 
which this blood is found. The blood is effused in interspaces 
beneath the peritoneum and elsewhere, as the effect of a rupture of 
some vessel; but while the effusion may be, and, perhaps, generally 
is, the result of a ruptured vessel of the' ovary, the blood sometimes 
also arrives in the peritoneal cavity from the uterus through the 
Fallopian tubes. We are not yet able to decide which of these cir- 
cumstances is the more common. 

This accident happens most frequently at the time of menstruation, 
or very near it. As an accompaniment of menstrual congestion, the 
bloodvessels of the whole genital organs are greatly distended, and in 
certain cases this turgidity becomes too great for their capacity, and 
a rupture is caused at some particular place ; or, the cavity of the 
uterus being filled with a profuse flow into it, the blood regurgitates 
through the tubes into the peritoneum. It is not likely, however, 
that any considerable effusions are thus caused, so that the sudden 
and copious collections sometimes observed must be accounted for 
upon the supposition that a small arterial twig has given way in the 
ruptured ovisac at the time of the escape of the ovum, and poured the 
fluid rapidly into the sac formed behind the uterus by the descent of 
the peritoneum. The instances I have observed were more frequently 
connected with cases of disordered menstruation, but I have also seen 
the accident in patients whose menses seemed normal. 

Dysmenorrhoea may be regarded as the most common deviation 
accompanying misplaced menstruation. 

There can be no doubt but that effusions of blood, in every respect 
similar to misplaced menstruation, are caused by the condition of the 
uterus and appendages in abortion, after labor, and as the result of 
other causes of intense congestion ; but when so the modus in quo is 
precisely the same, the congestion being caused, not by the menstrual 



MENSTRUATION AND ITS DISORDERS. 331 

molimen, but by the congestion of pregnancy and morbid excitement 
which sometimes attend these two states, — rupture of a small vessel 
or regurgitation being the immediate condition. 

Sanguineous collections arising in this way may be minute in size, 
but sometimes the quantity of blood is dangerously and even fatally 
large. The small collections are forced into places where distension 
is most difficult, as in the cellular tissue, while the large effusions are 
met with in the peritoneal cavity. Immediately after the blood is ex- 
tra vasated changes begin to take place in it and in the tissues occupied 
by it. Inflammation to a greater or less degree almost always is the 
result. In a mild grade the inflammation causes an effusion of serurm 
which augments the bulk of the accumulation and gives the appear- 
ance of much blood, when in reality there is but a small quantity. 
When this is the state of things, the disappearance of the tumor by 
absorption may be expected in a comparatively short time, and we 
often see it removed in a very few weeks. 

Dr. G. Bernutz has lately studied the pathology of uterine hemato- 
cele, and presents his views in a series of interesting articles (Arch. 
de Tocol, March, April, and May, 1880). The most important con- 
clusions of this study are summarized by Bernutz as follows : 

"1. Intraperitoneal uterine hematocele may arise in two entirely distinct and 
different ways. 

"2. In one case, which may be termed ' classic ' hematocele, hemorrhage takes place 
from rupture of the products of extrauterine gestation, or from rupture of some of the 
internal organs of generation, or the escape of the blood which had distended the 
oviducts into the abdominal cavity, where a secondary peritonitis is set up by its 
presence, this inflammation leading to incapsulation of the bloody collection. 

"3. In other cases the hematocele is the result of a primary pelvi-peritonitis, the 
hemorrhage occurring at a period more or less remote from the incipience of the 
serous inflammation. In this case the disease is a secondary manifestation of inflam- 
matory action, and its true origin is found in the newly-formed membranes lining the 
pelvic peritoneum. 

"4. These neomembranous hematoceles may be symptomatic of various conditions. 
Thus they may indicate an acute pelvi-peritonitis in a woman who was previously 
attacked by a more or less severe inflammation of the pelvic peritoneum, or they may 
point to a repetition of former subacute inflammations, or, in fine, to a chronic pelvic 
peritonitis of a particular kind. There are, therefore, two varieties of hematocele 
symptomatic of pelvi-peritonitis, each of which has a pathogenesis of its own. 

"v. In the hematoceles denoting an acute or subacute peritonitis, the hemorrhage 
arising in the newly-formed membrane is from the outset rather profuse, being com- 
monly determined by menstrual congestion. For this reason an intraperitoneal hema- 
toma becomes at once manifest. Frequently it becomes a matter of difficulty to dis- 
tinguish between the two kinds of hematocele unless the period of incipiency has been 
observed by the physician. Fortunately the practical importance of this fact is not 
very great, since the treatment is essentially similar in both varieties of the disease. 
In the second form of hematoceles, which alone exactly corresponds to Virchovv's de- 
scription, the hematoma is the result of scarcely suspected morbid action, which is very 
well indicated by the name of hemorrhagic pachy-pelviperitonitis. Under the influence 



332 METATITHMENIA. 

of this chronic process the pelvic peritoneum is occupied by stratified patches of new- 
formed membrane. In this way it becomes thickened, as it were, and slight hemorrhage 
takes place between the superimposed lamella?, thus forming interstitial blood-cysts. 
These hematoceles are strictly analogous to similar tumors of the tunica vaginalis.* 

The intensity of the inflammation is frequently much greater, pro- 
ceeding through the stage of serous effusion to the production of 
fibrinous deposit. A hard tumor is the result. This again may re- 
main for a longer or shorter time, and then very slowly disappear, or 
only be partially taken away, leaving a permanent hardness, or, what 
is not unfrequently the case, proceed to suppuration and discharge in 
some way. 

I have seen as many as two cases terminate fatally by the exhaus- 
tion of suppurative fever without the discharge of the contents of the 
tumor. When suppuration is fairly established by the inflammation 
thus arising, exulceration and evacuation follow as a general rule. 
The vagina is most frequently perforated by the ulcerative process, 
but the lectum, bladder, or uterus may serve as the conduit of dis- 
charge. If the inflammation is of an acute character, and the steps 
in the process of evacuation rapidly succeed each other, the character 
of the discharge will partake largely of a bloody quality ; but should 
the time required by exulceration be considerable, pus will prevail in 
the composition. In any case, however, the discharge is a mixture of 
pus and changed blood. This last is sometimes very greatly changed, 
sometimes but slightly. In rare instances the peritoneum is inundated 
by rupture into its cavity of this mixture of pus and blood, and over- 
whelmed with a general inflammation, soon resulting in death. I 
have seen cases of this kind, which were verified by post-mortem ex- 
amination. 

After absorption in cases attended with the milder grade of inflam- 
mation, very slight traces, if any, can be found by examination of 
the patient. When effusion of fibrin takes place, displacements, per- 
manent adhesions of the uterus and other parts, and deformity, will 
be left behind, slight or considerable, as the .amount of deposit was 
small or great. These changes will, of course, be greater after the 
process of suppuration and discharge has been reached by the inflam- 
mation. Fistulous and tortuous openings may also embarrass the 
convalescence of the patient, or even by their long continuance ex- 
haust her. 

Symptoms. 

The symptoms vary in different instances. The attack is generally 
sudden and well marked. During the menstrual flow, or it ma}' be 
just before or after, the patient is seized with severe pain in the hypo- 

* American Journal of Obstetrics, January, 1881. 



SYMPTOMS. 333 

gastrium or one of the iliac regions. Frequently there is also a sense 
of faintness, sometimes slight, but often it amounts to complete syn- 
cope. In the place of faintness there are sometimes coldness, tremors 
and palpitation of the heart. The pain becomes persistent, and, per- 
haps, less severe, but not unfrequently it increases for a considerable 
time and then gradually diminishes. After the inception the pain 
usually spreads over the abdomen to the back and hips, and some- 
times down the thigh and leg. As the pain becomes greater or extends 
over a greater space, febrile reaction is developed, generally moderate 
in grade, but occasionally excessive; the pulse becomes rapid, the 
heat considerable, and the patient complains of great depression and 
thirst. The abdomen increases in size and becomes tympanitic, while 
there may be a distinct tumidity and hardness felt in one of the iliac 
regions ; sometimes the hardness extends over the hypogastric to the 
other iliac. This hardness and swelling may scarcely rise above the 
pelvic brim, but it not unfrequently is perceived extending as high as 
the umbilicus. It is not much, if at all, tender to the touch. It is 
irregular in its outline also. In very rare instances the effusion 
takes place slowty, the symptoms are developed quite gradually, and 
the time of the beginning is not so definite, but the subsequent course 
is apt to be the same. 

After the symptoms are fully manifested, they pursue a course cor- 
responding to the grade of inflammation which is awakened by the 
effusion. In some cases the inflammation around the effusion is active 
and intense, and continues with severity until suppuration and exul- 
ceration end the process. Obstinate constipation is frequently present. 

Of course the fever is corresponding in grade and persistence, pass- 
ing through the high grade to hectic, attended with all its exhausting 
discharges. If the inflammation is less acute, the fever may be per- 
sistent for weeks, and sometimes for months, but of more moderate 
grade, until it gradually subsides, or slowly ends in suppuration and 
discharge. Active exercise aggravates the symptoms. Fortunately, in 
the large majority of cases, the amount of the effusion is small, the grade 
of inflammation slight, and the duration but a few days or weeks. 

There are two ways in which individuals are rendered miserable 
by the frequent recurrence of this trouble. One is, when all the 
symptoms subside entirely for months, and then return. The tumor 
entirely disappears, the inflammation is wholly gone, and the patient 
feels that she has fully recovered her health, when, suddenly, during 
a menstrual flow, she is again seized with pain, swelling, fever, etc., 
which again subsides to be repeated more or less frequently. I have 
a patient who has suffered attacks of this sort perhaps twenty times 
in the last six or seven years, in whom the tumors have at different 
times been mistaken for ovarian or uterine tumors. In the other way 
the subsidence is only partial; there is all the time some tumidity, 



334 METATITHMENIA. 

some inflammation, and more or less sympathetic suffering, with occa- 
sional severe returns. More blood is effused, the tumor is increased 
in size, and the inflammation intensified, and all subside to a partial 
extent and return again. 

When the tumor is much inflamed and suppurates, it may suddenly 
discharge through the vagina ; all the urgent symptoms readily sub- 
side, and the patient becomes convalescent. Again, the discharge is 
sometimes slow and difficult, the relief is imperfect, and a protracted 
convalescence the result. But sometimes, after a course correspond- 
ing to the above description, sudden and general peritonitis is lighted 
up by extension of inflammation from the sac, or a discharge of some 
of its contents into the peritoneal cavity. 

The discharge is generally fetid and highly irritating, consisting of 
partially decomposed blood, pus, and ichor. It is always offensive 
compared with discharges from an ordinary abscess. I have seen one 
or two instances in which the general symptoms were not manifested 
at all, nor did the pain amount to anything more than an incon- 
venience, not very difficult to bear. 

It is interesting to observe the effects of this misplaced menstrua- 
tion upon the flow per vias naturales. Occasionally no effect seems to 
be produced, the flow being natural in quantity and duration j in 
fact, it is just at the time of the cessation of the discharge that effu- 
sion into the tissues takes place, but at other times there continues for 
many weeks a constant stillicidium of blood. Or, occasionally, — 
when the menses occur during the course of the symptoms, — the 
amount of discharge is very much increased. I knew one patient that 
had a constant slight sanguineous discharge from the vagina for six 
months, and at the regular menstrual periods copious hemorrhages. 
In some cases the flow is more scanty than usual. 

Diagnosis. 

There are several conditions with which this sanguineous effusion 
may be confounded, if some caution is not observed. Inflammation of 
pelvic cellular tissue, or pelvic abscess, are the ones most likely to be 
mistaken for metatithmenia,, or this last for the first. And as I have 
already shown, abscess is sometimes the result of misplaced menstrua- 
tion, the effusion in the tissues exciting intense inflammation, which 
proceeds to the stage of suppuration. 

In cellulitis the inflammation is not ordinarily ushered in by the 
same suddenly occurring acute pain and faintness. Chilliness and 
fever are more marked from the beginning, the pain usually com- 
mencing after the fever has begun, or, at least, increasing after the 
fever is established. The tumor above the linea ilio-pectinea is not 
perceptible for many hours, oftener one or two days ^ it is extremely 
tender, and even in its outline. 



peognosis. 335 

In metatithmeriia the tumor is observed in a few hours, and is not 
so very tender to the touch. It may be handled and pressed upon 
much more freely than the tumor of simple inflammatory origin. If 
examined per vaginam the inflammatory hardness and swelling is 
very firm. It is usually lower down and more to one side. The 
tumor from sanguineous effusion is quite elastic at first, and presents 
an edgelike projection down behind the uterus, entirely below the os 
and cervix. The finger may be pushed up between the cervix and 
the tumor, and the thick convex edge of the latter reminds one of a 
thick cake. There is very little tenderness, and vessels may almost 
always be felt pulsating over this projection. I need not say that this 
is never the case in the early stages of cellulitis. The vessels in this 
last are obliterated by fibrinous and serous effusion. 

If inflammation of a high grade speedily follows the effusion of 
blood in the tissues, the symptoms of the two may be so intimately 
blended as to make it doubtful how the tumor began, and, in fact, it 
may be converted into pelvic abscess. 

Tumors of the uterus, under certain circumstances, may be con- 
founded with the tumor of sanguineous effusion; but their firmness, 
the want of conformity to the shape usually assumed by this last, the 
enlargement of the uterine cavity, our ability to isolate them by the 
fingers and probe, their gradual, unperceived growth, and their mo- 
bility, will almost always suffice to make the distinction manifest. 

From ovarian tumors it may be distinguished by the more regular 
outline, fluctuation on percussion, less grave symptoms, gradual de- 
velopment, absence of the projecting edge behind the uterus, the want, 
of the beating vessels, etc., in ovarian growths. 

Displacements of the uterus may always be made out with great 
certainty by introducing the probe into its cavity to ascertain the di- 
rection of the fundus, and correcting its deviations. Hence the diag- 
nosis need not be long embarrassed by any question in reference to- 
them. Retroversion of the impregnated uterus is constantly attended; 
with great urinary distress, while metatithmenia seldom is. 

Extrauterine pregnancy, perhaps, in some instances, more nearly 
resembles it than any other, but the enlarged and flaccid cervix, open 
os, dark color, and enlarged cavity, in this sort of pregnancy, and 
their absence in the accident we are considering, will suffice to dis- 
tinguish between them. 

Prognosis. 

The dangers to be apprehended in uterine hematocele arise from : 
1st, the shock of the effusion in the peritoneal cavity, which, however, 
is not generally considerable ; 2d, fatal exhaustion from the amount 
of effusion in the abdominal cavity ; and, 3d, inflammation and its 
effects. From inflammation we may fear death, permanent damage 
to the organs about the pelvis, and great suffering. Very few patients 



336 METATITHMENIA. 

escape without protracted suffering, often for weeks, and sometimes ' 
months. 

Damage to a greater or less degree frequently follows the displace- 
ments, adhesions, perforations, and thickening of the uterus, vagina, 
rectum, and bladder. The exhaustion of protracted febrile excite- 
ment; the perspiration, diarrhoea, and vigils not very seldom wear 
out the vital resistance of the patient, who is often of a very delicate 
constitution ; or sudden and violent inflammation of the peritoneum 
overwhelms and destroys her. 

The prognosis in any given case will be governed by the intensity 
of the symptoms and the comparative strength of the patient. If the 
amount of the effusion be large, and there be but little inflammation, 
the prognosis will be more favorable than if the effusion be small and 
the inflammation great. In fact, we may with great propriety form 
our prognosis by the amount and intensity of the inflammation alone, 
as it is almost the only source of danger. 

As before observed, a cause of death, though not frequent, should 
nevertheless be mentioned as influencing the general subject of prog- 
nosis in misplaced menstruation, viz., a fatal amount of extravasation 
of blood in the peritoneal cavity. More than one case is recorded in 
which there was fatal prostration, coming on and pursuing its course 
in a few hours, which, when examined, revealed, as the source of an 
extensive and copious hemorrhage, the ruptured twig of an artery on 
the ovary. Of the many cases that come within our observation, how- 
ever, the number that thus prove fatal are extremely few. 

Treatment. 

The three great facts of this accident — hemorrhage, pain, and in- 
flammation — afford us sufficiently plain indications for treatment. 
It is very seldom that we are sent for, or in any way see these cases, 
until after the hemorrhage has exhausted itself or been stopped by 
backward pressure, after filling up the space into which the bleeding 
takes place. Should we, however, meet with an instance during the 
hemorrhagic stage, it would be very proper to make use of ice to the 
pelvic region, perfect quiet, and astringents internally, until the effu- 
sion ceased; but, as I said before, such opportunities seldom offer 
themselves. The cases as we ordinarily see them have proceeded 
through this stage; the effusion, in fact, is generally accomplished in 
a few moments, or at most in very few hours. When we see the 
patient, she is either suffering with pain and prostration or coldness, 
the primary effects of the hemorrhage ; or pain, fever, and inflam- 
mation, and our treatment will be conducted according to the con- 
ditions in these respects. Our resources in the first condition will lie 
in the use of opium or other anodyne, to relieve the pain as much as 
may be necessary, and if the prostration or chilliness be considerable, 



TREATMENT. 337 

to stimulate sufficiently to establish equilibrium in the circulation, 
but not febrile reaction. In very many cases it will be sufficient to 
keep our patient quiet, and place her upon moderate anodyne treat- 
ment, good nourishing diet, and perhaps, after the first week or two, 
tonics, and she will slowly rally from the first shock, absorption of 
the blood will result, and she soon will recover her health. In these 
moderate cases we cannot be too careful not to overdo the treatment. 
The patients will generally recover spontaneously in a few days or 
weeks. 

But another class of cases occur, as I have already said, in which 
inflammation very soon succeeds the sanguineous effusion. A knowl- 
edge of the mischief which this inflammation brings about should 
make us prompt in meeting it with appropriate remedies. If the 
inflammation runs high, adequate antiphlogistic measures will be 
indispensable to a favorable course. An active cathartic of calomel 
and jalap or some other alterative cathartic should begin at once, 
while at the same time, if deemed advisable on account of the force 
of reaction, we may apply a dozen or twenty leeches. These may be 
followed by the tincture of veratrum viride, in doses of two drops 
every hour, until the pulse is brought down to its natural frequency 
and volume, if not below these conditions, and then continue its use 
in less doses, or the same less frequently repeated, for some time. 
According to my observations, the most of adults will be held at this 
point by taking as little as one drop an hour ; some will require more 
and some less. The energy of this antiphlogistic course must be 
graduated by the force of inflammation ; but few cases will require as 
much as is described here. Should the inflammation advance to sup- 
puration, the remedies required will be supporting ; at first, sulphuric' 
acid and quinine, and afterwards these with wine or other stimulants, 
nourishing diet, etc. These cases are often so protracted, the patients, 
are so much prostrated, and suffer so much pain, that great skill willi 
be called for to adapt the anod}^nes, tonics, and nutrients to the vari- 
ous conditions of the patient for so long a time. 

A question associated with the progress of inflammation, and one 
of great importance, is the propriety of evacuating the fluid. To 
evacuate the blood soon after its extravasation would seem to remove 
the cause of inflammation, and thus avoid it. To say that an early 
evacuation of the effusion would never be proper is perhaps to assume 
an extreme position, and there may be cases where such evacuation 
is advisable, but I think the number requiring it must be very few. 
Indeed, I should fear inflammation, from the sudden discharge of a 
large amount of blood from the peritoneal cavity, almost as much as 
if it were allowed to remain in it. There is another condition in 
which an operation for discharge of the contents of the tumescence 
is less a question of doubt, viz., when pus has become mixed with 

22 



338 METATITHMENIA. 

the blood, on account of inflammation. It is very important in 
some instances to puncture and discharge the fluid. When the pa- 
tient is being worn out by the protracted course of the disease, and 
the sweat and diarrhoea which so often attend it, we must interfere 
surgically for her relief. And again, when the fluid is increasing, 
and the tumor rising in the abdominal cavity, without showing any 
disposition to " point " in the pelvis, or any other place where it is 
desirable to have it do so, there is clanger of the discharge of the pus 
and blood in the peritoneal cavity by rupturing the sac above, and 
we must anticipate it by choosing the place and mode. When we 
have determined to relieve the distension by puncture, we ought to 
use an exploring-needle or trocar to ascertain the contents before 
evacuating them. After being satisfied by this corroboration of our 
diagnosis, we may plunge a large trocar, or even a knife, into the 
most dependent part of the tumor. This point will almost invariably 
be immediately behind the uterus, but occasionally it will be at the 
side of the pelvis. 

After free puncture^ either with the trocar or knife, the discharge 
readily takes place, and the patient immediately experiences great 
relief. If the puncture is made to remove the blood before inflam- 
mation has begun, the evacuation may be more difficult, as it is often 
coagulated ; in that case the opening must be made large with a knife, 
and if the blood does not easily flow, the finger may be introduced 
to break up the clots and facilitate their expulsion. After the con- 
tents are thus expelled as near as can be, they sometimes reaccumu- 
late and are again discharged, and repetitions of these processes lead 
to still more chronic suffering, until the patient becomes a permanent 
invalid, or dies from such long-standing exhaustion. We may, with 
a good deal of certainty, cause contraction, granulation, and oblitera- 
tion of the cavity, by injecting it with iodine, wine, or other irritant. 
The best way to secure efficiency in injections is to introduce through 
the fistulous opening, or one made for the purpose, a small flexible 
catheter, so as to reach the bottom of the cavity and throw the fluid 
through this tube. We thus place the fluid used in full strength in 
contact with the walls of the cavity, while the injection thrown out of 
a common syringe will mix it up with the contents of the sac, and 
thus dilute it. 

Chronic Retrouterine Hematocele. 

I have met with a considerable number of hematoceles that did not 
terminate by absorption or suppuration, but remained in a latent 
condition, sometimes for years, and then became the subjects of change 
in their contents which rendered radical treatment indispensable. 
In the history of many of these cases the essential facts necessary to 
lead to a rational diagnosis are lost. 



CHRONIC RETROUTERINE HEMATOCELE. 339 

The time when the effusion occurred is so remote that many of the 
symptoms have been forgotten, or, taking place contemporaneously 
with an abortion, or paroxysm of dysmenorrhea, and the symptoms 
of hematocele were so blended with those of the other condition that 
they escaped notice. Not unfrequently our attention is called to these 
cases for a long time passing for retroversion of the uterus, in the 
hands of inexperienced practitioners without being recognized. 

After a greater or less length of time some of them undergo rapid 
increase of size, from an accumulation of serum, while others grow 
more slowly, but still become decidedly inconvenient tumors. 

One of the former kind has quite recently come under my notice. 
The patient was twenty-four years of age, the mother of two children, 
enjoyed good health until two years since, when she had, without 
any assignable cause, severe flooding, and was thereafter confined to 
bed for several weeks. She gradually recovered sufficiently to very 
poorly attend to her household duties. She did not have the advice 
of an experienced practitioner until three or four months before she 
came under my notice. Her physician at that time discovered a 
retrouterine tumor that extended above the brim of the pelvis, with 
the most prominent elevation on the right side, where it arose one 
and a half inches above the pubis. When first observed the lower 
portion of the tumor extended about an inch below the cervix uteri. 
From that time the tumor grew perceptibly until, at the time she 
came to me, the posterior cul-de-sac was very tensely distended. The 
lower end of the tumor was elastic, but too tense for undoubted fluctu- 
ation. The upper part of the tumor remained as above described. 
Dr. D. T. Nelson examined the patient on the same day, Thursday, 
the 24th of February, 1881. We requested her to call again on the 
27th of the same month, or three days later. When she came again 
for examination we were both astonished at the rapid increase in size 
manifested at the lower end of the tumor. The lower end of the- 
tumor was so much larger, and distended so far down as to begin to 
separate the external labia. The question with us was between a 
fungus or malignant tumor, behind and attached to the uterus, or an 
old hematocele. She was at once admitted into the Woman's Hos- 
pital, and the next day a small trocar was thrust into the tumor for 
exploratory purposes. 

A large amount of reddish serum was ejected with great force 
through the canula. I then made a small incision by the side of the 
trocar, through which I introduced my finger, and enlarged it so that 
I could introduce two fingers into the cavity. The fingers at once en- 
countered large deposits of macerated fibrin clinging to the wall of the 
cyst. These were separated as far as practicable, the cavity thoroughly 
washed out, and several pledgets of cotton saturated with tincture of 



340 METATITHMENIA. 

iron introduced. The serum contained albumen and the coloring 
matter of blood. 

A very remarkable case, with the commencement of which I was 
cognizant, is recorded in the first volume of the Transactions of the 
American Gynecological Society, by George H.. Bixby, M.D., of 
Boston. 

I saw the patient and attended her for three or four months after 
the effusion occurred and diagnosed retrouterine hematocele. During 
the time I attended her the tumor decreased decidedly, and I fully 
expected it to be entirely absorbed. The patient, as Dr. Bixby ob- 
serves, passed out of my care, but remained in Chicago, where I could 
know somewhat of her condition. 

She was an invalid during the whole seven years intervening be- 
tween my attendance and the time she went to Boston. As she was 
leaving Chicago for Boston she desired me to make an examination. 
The tumor was easily recognized at that time, but was not large. I 
subjoin Dr. Bixby's description of the case after she went to Boston: 

"Mrs. H , aged thirty-nine, a resident of Boston, consulted Dr. Mack, of St. 

Catharine's, Ontario, for an obscure pelvic tumor. On the following day I was called 
in consultation. The patient was of dark complexion and nervous temperament. 
Menstruation, which first appeared at eighteen and recurred at intervals of three 
weeks, was scanty and painless. In her youth she was unusually fond of outdoor 
sports, and later in life indulged in horseback exercise. She was married at twenty- 
one, and supposed she miscarried two years later. Seven years previously, while 
under the care of Professor Byford for uterine disease, she became the subject of hema- 
tocele, but shortly after passed out of his hands. For two years Mrs. H. had been 
suffering from a peculiar pain in the left ovarian region, and also from renal and 
vesical derangements. She described the pain as occurring in paroxysms, at first light, 
gradually increasing in intensity until almost, insupportable, then as gradually sub- 
siding. Soon after the recurrence of the above symptoms her attention was directed 
to a tumor the size of a small orange at the seat of pain. In the dorsal position, with 
the limbs flexed, percussion gave evidence of a well-defined dulness in the left ovarian 
and superpubic regions; by bimanual palpation unmistakable fluctuation. The uterus 
was fixed, and lateroverted to the right; its cavity two and one-half inches in depth. 
Exploratory puncture (through Douglas's fossa), with a small trocar by Dr. Mack, 
confirmed the existence of fluid. Three pints of a light straw-colored serum were 
withdrawn by aspiration, which completely emptied the cyst. The result of an analysis 
by Dr. Fitz, of Boston, was as follows : ' A clear, light reddish-brown, odorless, slightly 
alkaline fluid, sp. gr. 1020; absence of sediment ; abundance of albumen, it becoming 
solid by boiling; abundant chlorides and sulphates. Microscope reveals numerous 
oil-globules, a few round cells with large nuclei and a small amount of granular pro- 
toplasm ; an occasional granular corpuscle. If it be a question between ascitic or 
ovarian, the latter is probable.' Noth withstanding this result we were disposed to 
consider this case one of encysted dropsy of the peritoneum following hematocele. 
Being now intrusted to my care she was ordered rest in bed, no treatment. Not the 
slightest reaction followed the operation, and in the course of three weeks she resumed 
her ordinary duties. 

" Dr. Mack was disposed to attribute much of the pain as well as the renal derange- 



DIAGNOSIS. 341 

ment to pressure upon the nervous filaments of the tissues in the vicinity of the cyst. 
The description of the pain and the renal and vesical symptoms were at least sugges- 
tive of some interference with the functions of the ureter by pressure from the cyst. 

" The following letter from Dr. Byford, received since the operation, tends to con- 
firm the diagnosis : 

"' Dear Doctor : lean emphatically indorse your diagnosis and proposed treat- 
ment. In my own practice I have met with but two cases of serous accumulation 
after hematocele. One was cured by a single tapping with the aspirator, the other 
by establishing a permanent drain from the cavity. In the last case reaccumulation 
took place. I then punctured with a large trocar, and passed through the canula 
a flexible catheter, and left it in position. The cure was effected in about three 
weeks.' " 

Diagnosis. 

The diagnosis of these old hematoceles is not always easy. The 
history, if the patient can intelligently trace it, will often lead to a 
strong suspicion of the character of the tumor. The primary attack 
may date back several months, and sometimes as many years, and 
may have been distinguished by symptoms arising from the continued 
presence and occasional augmentation of the tumor, indicative of some 
form of pelvic disease. Not unfrequently, however, the commence- 
ment is so obscured by attendant circumstances as to evade the most 
diligent inquiry, when we shall be obliged to depend upon recent 
developments and physical examination for a diagnosis. 

In many cases the patient will have suffered a long time from pelvic 
symptoms, and be aware of the existence of a tumor. The tumor is 
often mistaken for growths, as ovarian or uterine tumors, and even 
extrauterine pregnancy r . In hematocele the tumor is situated behind 
and adherent to the uterus. The uterus is pressed strongly forward 
and upward, and generally to the right side, so that the fundus may 
be felt above the right ramus, itself simulating a tumor. Generally 
the top of the hematocele may be recognized by pressing the hand 
down into the brim of the pelvis, while the lower end will be found to 
fill up the cul-de-sac of Douglas, and distend it very greatly. The 
distension is especially downward, reaching occasionally as low as the 
external organs. 

I should regard the forcible downward distension of the cul-de-sac 
with fluid as a very important, if not a distinctive sign of chronic 
hematocele. The upper part, or fibrinous covering of the hematocele, 
is inelastic and does not permit of distension in that direction, while 
the wall of the retrouterine pouch is elastic and permits distension. 
An ovarian tumor, a tumor of the lateral ligament, or an extrauterine 
pregnancy develops upward instead of downward. While any or all 
of these may be felt to occupy the cul-de-sac, they do not forcibly 
distend it downward. Instead of displacing the uterus upward as 
well as forward, they displace it forward at first, and afterwards down- 
ward. 



342 METATITHMENIA. 

The hardness and more globular shape of a fibroid tumor, situated 
in the retrouterine space, will generally enable us to distinguish it from 
an old hsematocele. An abscess is seldom situated immediately behind 
the uterus, and when it is there is generally so much hardness around 
the presenting fluid as to make the distension irregular, aside from the 
usual tenderness. 

When the diagnosis cannot be made in any other way the tumor 
may be aspirated. The fluid drawn from an old hematocele is well 
described in Dr. Bixby's case. The coloring matter of the blood is 
always noticeable. 

Treatment. 

The proper treatment of the chronic hematocele consists in evacu- 
ating it, draining the cavity, and frequent injections of some disinfec- 
tant solution, — the carbolic acid or permanganate of potash. When a 
sufficient amount of fluid is removed for diagnostic purposes the tro- 
car or aspirator needle may be taken as a guide for the incision. The 
incision should be made in the most prominent part of the tumor large 
enough to admit the finger. The index finger should be introduced 
through it, and be made to tear a large opening into the sac. The 
opening must be large enough to admit two fingers freely into the 
cavity. Large deposits of the fibrin of the blood will be found adher- 
ing to the inner wall of the sac. The removal of these coagula of 
fibrin is very important, for if allowed to remain they will undergo 
decomposition, and thus be the source of sepsis. The large opening 
I have recommended has the advantage of permitting the free use of 
the fingers for this purpose and the efficient cleansing of the cavity by 
injections. When carefully performed this operation causes little or no 
shock, and the patient usually recovers in two or three weeks from the 
effects of the evacuation. It requires several months for the sac itself 
to be removed by absorption. Eventually, however, it disappears to 
such an extent as not to be recognizable by an ordinary vaginal ex- 
amination, and with proper care the patient speedily recovers her 
usual health. 



CHAPTER XIV. 

CHANGE OF LIFE— MENOPAUSE AND SENILITY. 

At the period when woman ceases to menstruate various changes in 
her system occur, which constitute what is termed "change of life." 
The peculiar anatomical feature noticeable is progressive atrophy of 
the ovaries, uterus, and usually of all the other female organs, in- 
cluding the mammary glands. 

Dr. Tilt, in his excellent work on the Change of Life, says : " Puberty 
and the change of life are caused by anatomical changes, the one by 
ovarian evolution, the other by ovarian involution." I should say 
these two conditions were accompanied by, instead of caused by, the 
ovarian evolution and involution. 

The change of life is an important epoch in a woman's existence, 
for if not, as Dr. Tilt thinks, the cause of many diseases, it is contem- 
poraneous with a number of the most dangerous affections, and cer- 
tainly modifies very materially the course of others. When not ac- 
companied by disease it is normal, and usually leaves the woman, to say 
the least, in no worse condition than before it occurred. Generally she 
becomes more vigorous after it, and her prospects for life and health 
are increased. 

The change of life is gradual, requiring from one to eight, or even 
ten years for the processes of involution and changes in all the body 
to take place. The average of the menopause is forty-five years. 
While it may not always be the case I think a very early or very late 
menopause is abnormal in other respects than time. The cases that 
come about very early in life are much more frequently than otherwise 
caused by pathological conditions. Peculiarity of organization is the 
only way to account for the remainder. Such instances as have fallen 
under my observation were without exception preceded by diseases of 
the uterus and probably of the ovaries. I say probably, because the 
ovarian affection cannot always be diagnosticated with certainty. 
The late menopause I have not met with as often, and I have not been 
so clearly convinced of the condition of the patients as in the former. 
In such cases as I have noticed most of the women seemed to be pecu- 
liarly vigorous, though sometimes I have thought the long-continued 
functional activity of the genital system appeared to depend upon 
chronic hyperemia, caused by tumors, congestion, or inflammation. 

Simple cessation of the menstrual return is not the change of life. 
When the menses cease from a failure of the general powers, the term 
will not apply. 



344 CHANGE OF LIFE — MENOPAUSE AND SENILITY. 

The cessation of the menses does not always take place in the same 
way. Sometimes it occurs suddenly, with no change in the quantity. 
quality, or periodicity up to the last return, and with no premonitor}^ 
symptoms. At other times a change in the periodicity of the men- 
strual flow occurs as a premonitory symptom of its cessation, the in- 
tervals in some cases being irregular, in others steadily decreasing in 
time until complete cessation occurs. 

Xot unfrequently the menstrual discharges grow progessively less 
for ten or twelve years before they completely cease. By this method 
the change of life becomes an accomplished fact only after a compara- 
tively protracted transitional period. Sometimes a severe hemorrhage 
is succeeded by the menopause. 

Numerous other methods exist by which this important change is 
brought about : those which I have mentioned are the more common 
ones. 

There are probably no reliable symptoms, not immediately connected 
with the cessation of the menses, to indicate the apjDroach or even the 
progress of the change of life if the woman is in a perfectly healthy 
condition. The change, when a healthy one. is so gradual that the 
various organs and the nervous and vascular systems have ample time 
to accommodate themselves to the difference in the functions of the 
sexual system. 

Does the change of life give origin to the diseases, or to any of them, 
occurring at that time ? My opinion is that it does not. I believe them 
to be merely coincident. Fibroid tumors of the uterus and cancer of 
various organs do frequently occur about the time of the menopause, 
but they also are often met with both before and after that period. 
The long list of diseases and symptoms enumerated by Dr. Tilt are 
only evidence that the woman was diseased before, or became so at the 
time, from other causes, instead of indicating the change of life as the 
cause of them. 

Yet there is little doubt that the progress of existing diseases is 
modified by the changes in the circulation, nutrition, and nervous 
energies which occur at the change of life. In different parts of the 
present work I have alluded to this in describing the diseases in per- 
sons of different ages. Women undergoing the change of life who are 
not the subject of disease require no special management or treatment. 
It is well to have them as nearly as possible cured of the inflamma- 
tions, congestions, and displacements which afflict them, as that will 
cause the process to be more easily and naturally accomplished. How- 
ever, I think we need not fear that the change of life will be disastrous 
either as a cause of disease or by injuriously modifying those already 
existing. As elsewhere stated, we usually expect chronic inflamma- 
tion and its consequences to be benefited, if not entirely cured, by 
senile involution of the organs of generation, and we also often find 



CHANGE OF LIFE — MENOPAUSE AND SENILITY. 345 

the fibroid degeneration and growths of the uterus arrested in their 
progress by the same change. In all respects, when not complicated, 
we may expect the menopause to be a favorable crisis in woman's life; 
and even when contemporaneous with diseases, it is much more likely 
to beneficially influence their course than cause them to be aggravated. 
In all my expressions on the subject I have steadily kept in mind the 
fact that the menopause is but an incident among the processes which 
go to constitute the change of life. Senility in woman, after a com- 
plete change of life, is a state in which she is free from the embarass- 
ments connected with the active sympathies of the genital organs. 
Her diseases are more simple and less liable to become complicated. 
They are no longer female in their nature but fall into the category of 
common diseases. Exceptions occur to this statement. We do, though 
rarely, find some of the diseases, such as metritis, and even ovaritis, 
etc., commencing in old age. When they do originate in this stage of 
life, as the genital organs are in a state of feeble vitality, and the gen- 
eral system is incapable of exerting the same recuperative force as in 
earlier life, we may expect them to be both more obstinate in their re- 
sistance to treatment and more disastrous in their course. 



CHAPTEK XV. 

ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 

Causes. 

Acute inflammation, not arising from specific causes, generally 
affects the fibrous portion or substance of the walls of the uterus. It 
almost always, if not quite, pervades the whole of the organ, the 
fundus, body, and cervix. Exposure to cold is the most frequent 
cause. The cold may be applied to the general surface when the 
uterus is in a state of turgescence from menstrual congestion, sexual 
excitement, or incomplete involution after labor or abortion. The 
same agent acting upon a portion of the surface, as the feet and legs, 
under a similar condition of the organ, may give rise to the same dis- 
ease. It is not likely that cold, however applied, would be a sufficient 
cause, but for the predisposing condition I have mentioned. The ex- 
citement of excessive sexual indulgence may be carried so far as to 
cause a moderately acute inflammation of the substance of the uterus, 
as also blows upon the abdomen, etc. 

It is not a very common disease, and yet I do not think it can be 
regarded as an infrequent affection. 

Symptoms. 

In speaking of the symptoms of the disease, I wish the reader to 
bear in mind that their intensity will vary from a mildness that will 
scarcely confine the patient to her couch to a very severe and grave 
disease, almost overwhelming the nervous system, with delirium and 
convulsions, and calling the stomach into excruciating sympathy with 
it. In considering the subject, I wish to be understood as attaching 
more importance to the suddenness than to the intensity of the attack 
in determining the nomenclature. 

It is somewhat owing to the exciting cause, as to the symptom 
which is likely to usher in the attack. If the cause is a moderate 
one, as excessive sexual indulgence, pain will generally begin some 
time before the general symptoms. If the cause is cold suddenly 
and extensively applied to a menstruating patient, chills and rigors 
may precede the pain. However that may be, when the case is fairly 
developed there is fever, aching in the back, pain in the head and ex- 
tremities, flushed face, and furred tongue. In addition to these general 
manifestations there is local pain, indicating the organ affected. This 
pain may be confined almost entirely to the sacrum and the lumbar 



PROGNOSIS — DIAGNOSIS. 347 

region if the inflammation is moderate, but generalty there is pain in 
the pelvis behind the pubis, or in one or both iliac regions. Some- 
times the pain radiates in several directions up the abdomen, down 
the thighs, and around the body. The pain is usually of a dull 
aching, but sometimes of a sharp character. In addition to these 
symptoms indicating inflammation in some of the pelvic organs, the 
nervous system is often affected with hysterical symptoms, convul- 
sions, coma, laughing, crying, or unreasonableness of some kind. I 
should have mentioned among the local symptoms dysuria and diffi- 
cult and painful defecation. Should the peritoneal covering become 
involved there is swelling and greater or less tenderness of the abdo- 
men. Nausea and even vomiting are not infrequent symptoms. 

After a week or more of this kind of suffering the symptoms gradu- 
ally subside, and the patient slowly recovers her usual health; or 
sometimes the subsidence of the pains is not complete, and she con- 
tinues to suffer with a chronic form of inflammation. The termina- 
tion is almost always in resolution or the chronic form of the disease. 
Possibly, in some exceedingly rare instances, the force of inflammation 
is spent in some circumscribed locality, and it proceeds to suppura- 
tion. I have lately seen an instance of this kind where the suppura- 
tion' was in the anterior lip of the cervix. 

Prognosis. 

The termination is so frequently in resolution or a moderate form 
of chronic inflammation, that we may almost always expect complete 
or partial recovery. Death probably never results in uncomplicated 
cases of acute metritis, but unfortunately we occasionally meet with 
grave and even fatal peritonitis, apparently resulting from extension of 
the disease from the uterus. It has been my misfortune to have lately 
met, in consultation, with two instances of this sort. Although the 
prognosis is favorable, as a general rule, so far as the recovery of the 
patient from the attack is concerned, it is not so favorable for the 
complete re-establishment of health, as the patient is likely to be 
affected with chronic inflammation in the body or cervix. Not un- 
frequently we trace chronic inflammation back to a moderate attack 
of the acute. 

Diagnosis. 

Inflammation of the cellular tissue beside the uterus, metatithmenia, 
rectitis, or cystitis, cause symptoms which may be mistaken for me- 
tritis. When doubt exists it may be easily and certainly solved by a 
digital examination. If the bladder is the seat of disease, the tender- 
ness complained of by pressing it between fingers in the vagina and 
others above the pubis will be sufficient proof; pressure may be made 
upon the rectum by including it between the introduced fingers and 



348 ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 

the sacrum. The inflammation at the side of the uterus, or cellulitis, 
causes tenderness and hardness close to the iliac bones on the side, 
and the hardness seems to be continuous with the bones. The 
greatest tenderness is therefore close to the side of the pelvis. In all 
these cases the uterus may be touched, provided it is not moved so 
as to press upon the inflamed part or organ without causing pain. 
If it is the seat of inflammation the tenderness will be confined to 
that organ, while all the rest are free from it, and may be handled 
freely. We should not forget that all these organs may be implicated 
in one great mass of acute inflammation, and all the pelvic contents 
be intolerably tender to the touch. In an examination to diagnosti- 
cate inflammation of the uterus, I need hardly say that a resort to 
instruments is unnecessary. 

Treatment. 

The intensity of the inflammation will govern us in the activity of 
treatment. If it is not attended with great pain or febrile reaction, 
although our remedies must be the same, there is no need of using 
them with the same energy. We should, however, bear in mind the 
great likelihood of leaving the chronic form behind, and be diligent 
in our medicinal and hygienic appliances when practicable, until 
every vestige is gone. If the attack is moderate, it may sometimes be 
interrupted in the beginning, by measures to induce a copious per- 
spiration, more particularly if caused by an exposure to cold. Even 
a smart attack may sometimes be relieved by a large dose of opium 
and a steam-bath, used within a few hours after the commencement 
of the symptoms. After the symptoms have become fairly established 
and have lasted for twenty-four hours, we must not expect to find im- 
mediate relief, and should begin the systematic use of antiphlogistic 
treatment. In the subacute form, a brisk cathartic, foot-bath, and 
fomentations over the uterus, should be followed by tart, antimony, 
muriate of ammonia, and calomel. 

Perfect quietude should be enjoined also, and rest at night may 
be insured by giving one grain of calomel, with twice the amount 
of opium, in a pill at bedtime. Continued for five or six days this 
will generally induce slight mercurial effect, when the pain and other 
symptoms will pretty surely subside. If they do not do so, a blister 
over or a little above the pubis will aid in banishing them. If the 
attack is severe, we ought to add to the above remedies the more 
immediately depressing. The patient may be bled from the arm 
until a decided impression upon the pulse is produced, or we may 
apply from ten to twenty leeches to the vulva and groins, as a de- 
pletory measure. In the country, where leeches cannot be had, scari- 
fication and cupping can be profitably substituted for them. Should 
arterial excitement be high after the depletory measure, the tinct. of 



ACUTE INFLAMMATION OF MUCOUS MEMBRANE OF UTERUS. 349 

verat. viride in doses from four to six drops every four hours, with 
the amnion, mixture, will be an efficient adjunct to our remedial 
measures. The calomel should be withheld as soon as its specific 
effects are produced. 

I should not discharge the obligation I feel to the student in the 
treatment of this disease were I not again to caution him against an 
imperfect cure of it. Very often it becomes chronic, and renders the 
patient miserable for years. We should try to avoid this consequence. 
Too early a resumption of duties and active exercise should be espe- 
cially prevented. When practicable, a continuation of treatment and 
avoidance of the causes which produced the inflammation are of 
equal importance. As a means of perfecting the cure which the more 
active treatment has brought about, the sedative effect of water affords 
us valuable aid. The sitz-bath and vaginal injections are the modes 
of using it. The sitz-bath ought to be used as much as the time and 
patience of the patient can be made to allow. An hour is short 
enough time, and two hours is better, twice or thrice in twenty-four 
hours. The injections should be copious, and may be used in the 
bath and of the same water. From two to four gallons of water ought 
to be passed through the vagina in this way each time the bath is used, 
by means of the rubber syringe. 

Acute Inflammation of the Mucous Membrane of the Uterus. — I do not 
know that I have ever met with an uncomplicated case of acute in- 
flammation of the mucous membrane of the uterus. Cases that I 
have seen have been connected with inflammation of the vagina, and 
have arisen as the effect of some poison directly applied to the mem- 
brane. Most of them were gonorrhceal, but in some I have been 
puzzled to determine whether the poison of this affection was the 
cause or not. Probably this poison gets into families, where and in 
ways it ought not, and thus deceives us. However this may be, I 
think one of the worst features of gonorrhceal inflammation is the 
frequency with w T hich it invades the mucous membrane of the uterus 
and the difficulty of completely eradicating it. It is very apt to lurk 
in the uterus after the acute symptoms are removed and the inflam- 
mation gone entirely from the vagina, and thus require treatment as 
chronic endometritis. 



CHAPTEE XVI. 

GENERAL CONSIDERATION ON " UTERINE DISEASE " OR 
HYSTEROPATHY. 

There is a long list of symptoms, called nervous, or sympathetic, 
which, although not exclusively confined to women, are more fre- 
quently found to manifest themselves in them. They were formerly 
regarded either as independent affections, or as having various sources 
of origin ; and although hysterical was the term usually applied to 
them, it was not definitely known in what manner they originated. 
Patient investigation has given us more definite and correct notions 
of them, and we have come to regard them as nearly always depend- 
ent on trouble of some kind in the sexual system. Medical men, 
however, are not united in the opinion that the symptoms alluded to 
are thus caused, but are divided into two well-defined parties with 
respect to uterine pathology. 

1st. There are those who believe that the uterus has very little sym- 
pathetic influence on the system ; that the diseases of that organ are 
more frequently the result of diseases in other organs than of inde- 
pendent origin ; that the symptoms accompanying and almost always 
found in connection with actual lesion of the uterus do not at all de- 
pend upon this organ ; that these symptoms may be cured without 
any attention to the condition of the uterus, and, in fact, whatever cures 
them, almost always cures the affections of that organ. 

2d. The other party holds the opinion that the sexual system of the 
female, in a state of disease, exercises a morbid influence over nearly 
the whole organization ; that this morbid influence is particularly ex- 
erted over the spinal and cerebral nervous systems ; and that the onty 
sure and permanent relief is found in the cure of the disordered con- 
dition of the uterus. 

Those who adhere to the latter view may be classified under two 
subdivisions, one of which holds that the sympathetic influence of the 
uterus is only manifested when that organ is inflamed or ulcerated, 
and that the cure of the inflammation and ulceration relieves the 
symptoms. The other maintains that inflammation and ulceration 
are only of slight, if indeed of any, importance ; while the cause of all 
the difficulty is some sort of displacement. 

It will probably surprise the student when he is told that all of these 
diverse and various opinions are held by gynecologists of equal emi- 
nence, integrity, and opportunity for observation. There is reason 
for surprise in this consideration, and yet this same diversity of opinion 



OR HYSTEROPATHY. 351 

exists in all departments of medicine ; for example, as to the nature 
and treatment of inflammation, as to the essential nature of typhoid 
fever and its treatment, as to the local or general origin of cancer, and 
the propriety of extirpation. How can this discrepancy be accounted 
for? It is not my purpose to answer this question at length, but 
merely to indicate a few obvious considerations, of which one is that 
the attention of medical men has been too recently directed with suf- 
ficient intensity to the points involved to enable them to make an 
induction full enough to convince by its results all the members of 
the profession of the correctness of any one view. This, therefore, is 
just the time when we meet with conservatism in the views of tem- 
perate and judicious investigators, as well as with the less laudable 
conservatism of those who have lived too long to improve. Another 
consideration is, that while judicious practitioners hold antagonistic 
opinions as to the nature of diseases, they pursue so nearly the same 
line of practice as to lead to similar results in the treatment of them. 
A third consideration relates to the power of prejudice, which forms 
in very many minds an invincible barrier against the acquisition of 
truth ; and the opinions imbibed in early education are those which 
are maintained the most persistently, sometimes in consequence of an 
unwillingness to learn, and sometimes even against the light of reason 
itself. From the pernicious influences of association and prejudice 
neither learned nor unlearned are exempt. 



CHAPTER X A' 1 1. 

SYMPATHETIC :»E KEFLEX SYMPTOMS 0? FTKEIXE DISEASE. 

Be. Scanzoki* says: The sympathetic phenomena which very 
distant organs so often present during the course of uterine diseases 
are of the highest scientific importance." They are the more impor- 
tant because our attention is more frequently called to them than to 
their original exciting cause. The secondary or sympathetic diseases 
often distress patients most, and the fact of their mentioning no other 
troubles may. without inquiry, mislead us into the opinion that they 
are independent affections. 

The general symptoms attendant upon uterine disease are primarily 
sympathetic and secondarily neurasthenic. The sympathetic are re- 
flex. An impression is produced on the ganglia of that portion of the 
sympathetic nervous system connected with the uterus and ovaries 
especially. Thus propagated it is conveyed along the nerve fibrillae 
to the genito-spinal centre, and from this reflected to all the organs 
with which the genital system is in sympathetic relation. 

The stomach is deranged in various ways ; the bowels, the liver, and 
the spinal and cerebral nerve centres become affected. The derange- 
ments of digestion interfere with nutrition, the blood becomes poor in 
the materials calculated to sustain the vigor of the nerve centres ; they 
become ansemic, and in this way nervous exhaustion occurs and we 
have with the original sympathetic symptoms, or succeeding them, 
neurasthenia. 

Y^urological writers, among whom are Drs. Weir Mitchell. Beard, 
and Profess : Jewell, ascribe neurasthenia to an exhausted state of the 
nerve centres. If I rightly understand what they mean by this it is 
that the brain and spinal cord have become damaged by overaction. 
I do not mean by damage, structural lesion, but a condition in which 
the cell action is slow, labored, and painful, because the parts have 
rked, and according to this method of interpreting the 
symptoms they prescribe rest as one of the essential parts of the cure. 
This is bo different from th Look at the subject that I will risk 

ncise statement of my views. 

I think that the nerve centres do not become exhausted, but that 
the blood circulating through them does become exhausted of the ma- 
terial necessary to promptly renew the loss during functional action 
of the nerve centres. On account of the want of general vigor, the 

* Diseases of Females, 



SYMPATHY OF THE STOMACH. 353 

heart and arteries may not transmit the blood through them in the 
usual quantity, but if the circulation is not deficient in quantity, the 
blood itself is deficient in quality. With a deficient supply of nutri- 
tive material their functions are performed irregularly and imperfectly, 
and there is neurasthenia. 

If my explanation of the origin of neurasthenia is correct, absolute 
rest is not so important to the cure as full feeding. 

We shall be able to study the general symptoms of uterine disease 
more profitably by taking them up separately as they are manifested 
by different organs, and without attempting absolute correctness in this 
respect, it will be practicable to present them in something like the 
order of frequency in which they occur. 

Sympathy of the Stomach. 

The stomach is apt to be disturbed as early and as frequently as any 
other organ by uterine disease. This is no more than we would ex- 
pect, considering how often and intensely it is influenced »by preg- 
nancy, and its great readiness to complication in most affectioDS of 
other parts of the system. Simple anorexia is one of the most com- 
mon of the sj^mpathies of the stomach, as is also its contrary, vo- 
racity; but occasional unbecoming, and even disgusting, depravity of 
appetite is also met with. Inappetency sometimes proceeds to the 
extent of loathing of food and to longing for inappropriate articles of 
diet. Nausea, with loathing of food and disgust at the smell of it, is 
another feature of stomach trouble; also frequent vomiting when the 
stomach is full; an absence of discomfort when it is empty, and the 
vomiting is sometimes worse when there are no ingesta, and nothing 
is expelled but some of its secretions, which are usually acid, but 
sometimes bilious. Gastralgia may occur when the stomach is empty ;; 
or during digestion, or immediately after swallowing food. The ca- 
pacity of the stomach to digest food of any kind is often impaired,, 
but more frequently some particular sort of food disagrees with and 
embarrasses digestion; in short, almost every form of disordered 
stomach may be looked for as the result of the sympathetic influence 
of diseases of the uterus upon that organ. The grade of functional 
disturbance may vary from the slightest inconvenience to that com- 
plete arrest of digestion which rapidly induces inanition and death. 
Extreme cases of indigestion, however, are not of frequent occurrence, 
and the disturbances are rather those of great annoyance than such 
as result in very serious impairment of nutrition ; and many patients 
who constantly complain of suffering very severely from sensitiveness 
connected with digestion attain to a state of apparent robust embon- 
point. 

23 



354 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

Sympathetic Disease of the Bowels. 

The bowels probably sympathize in diseases of the uterus next in 
frequency to the stomach, and their functional derangements are mul- 
titudinous. Constipation is very common. The bowels, in many in- 
stances, have apparently no natural tendency to move. I have one 
patient who assures me that she has often been fourteen days without 
any fecal discharge whatever, and that she dare not try how long she 
could go without it, but says that she always uses some means to pro- 
mote the alvine evacuations. In other cases constipation terminates 
with diarrhoea, and an alternation of diarrhoea and costiveness, which 
lasts from two to six days, is a constant and habitual state with the 
patient. In cases of constipation resulting from this cause, the con- 
stipation seems to depend upon a want of muscular tone in the intes- 
tines ; peristaltic action is deficient, and the appearance of the evacu- 
tions is in all respects natural, and their consistence proper. In other 
cases the secretions are deficient, and the stools are dry, hard, and 
small in quantity. But constant diarrhoea and irritable bowels are 
also frequent accompaniments of uterine disease. The passages may 
be profuse, watery, and exhausting, or profuse and fecal. A peculiar 
kind of discharge in cases of diarrhoea in uterine disease presents a 
muco-fibrinous cast of the intestines. The casts are sometimes quite 
tenacious and of variable length, from two to ten inches, and are often 
complete casts of the intestinal tube ; at other times there are shreds 
of false membrane of irregular shape and size. The discharge of 
these substances is usually attended with some dysenteric symptoms. 
The diarrhoea sometimes seems to be excited or aggravated by certain 
articles of food ; at other times one kind of ingesta seems to agree as 
well as another; and, again, the bowels may be quite regular, except 
at or near the period of menstruation. The irregularity is often en- 
tirely confined to that time. With or without diarrhoea there may be 
tumultuous gaseous commotion in the bowels ; they may be more or 
less distended, or without distension there may be annoying borboryg- 
mus and motion, from the gas passing from one part of the intestines 
to another, inducing the opinion that pregnancy exists. The gaseous 
distension of the abdomen is sometimes so extensive and permanent 
as to induce the overwilling patient to believe that it is caused by ges- 
tation, and being frequently connected with hysterical craftiness, she 
may impose the same belief on a careless practitioner. 

Sympathetic Affection of the Liver. 

Closely connected with and, of course, very much influencing the 
condition of the alimentary canal, is the condition of the liver. 
Sometimes the bile is poured out in such copious quantities as to 
induce full and free discharges of it from the stomach by vomiting, 



SYMPATHETIC AFFECTIONS OF THE NERVOUS SYSTEM. 355 

and to stimulate the intestines to copious bilious diarrhoea when they 
are not irritable, but subject to the ordinary stimulation of ingesta. 
This overflow of bile comes in paroxysms, and produces a sort of 
cholera morbus. When it occurs only once a month, it is apt to be 
near the time of menstruation, or it may return several times between 
the monthly periods. But there is often a persistent absence of secre- 
tion for a time, or this condition may alternate with the other ; or 
the bile, instead of finding its way into the alimentary canal, majr 
pass into the circulation and give the skin a jaundiced hue. When 
the functions of the liver are seriously disturbed, there is apt to be 
at one time a deficiency of bile, and at another a great redundancy. 
I have not seen this organ congested to any great extent, as observed 
by Dr. Bennett. But I have seen an enlargement of the spleen in 
such instances, though I have not supposed it to be the result of the 
influence of uterine disease. When copious effusions of bile take 
place somewhat suddenly, all the pain and spasmodic action observed 
' in bilious colic are likely to present themselves. 

Sympathetic Affections of the Nervous System. 

Much more distressing if not more serious suffering is experienced 
in the nervous system than in the digestive apparatus. Aches, pains, 
and complaints of evident nervous ailments are the peculiar province 
of uterine disease. There is hardly a disagreeable or even excruciat- 
ing sensation that these patients do not experience; and too often 
this real suffering is mistaken by the friends for imaginary, and the 
patient's complaints are treated with unreasonable impatience and 
rudeness by persons from whom she ought to receive kindness and 
sympathy, because her appearance does not correspond with her mor- 
bid sensations, as we are apt to observe them in other examples of 
disease. It is remarkable, too, and a fact that often impeaches them 
with insincerity in their complaints, — when the uninitiated are the 
judges, — that these patients will pass from a state of excruciating 
suffering and loud complaints, under a little excitement, to one of 
actual enjoyment and hilarity, or conversely. The transition from 
the excitement of private company, or a public party, gives way in 
a few minutes to a doleful condition of suffering and unappeasable 
complaints. The inconsistency of the complaints and enjoyments, 
the incapacities and the performances of these patients, are almost 
characteristic, — at least in their sudden alternation, — and are inex- 
plicable in any other way than by supposing that the pains in the 
different organs, to which they are referred, are more dependent upon 
the general nervous susceptibility than upon the organic disease of 
even trivial character. They are strictly neuralgic in their nature, 
and confined to the nerve-matter or tissue of the parts. A great num- 



356 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

ber of the disagreeable sensations and pains appear more frequently 
in particular parts, and hence may be distinctly referred to in this 
description. 

Accompanying Manifestations of Moral and Intellectual Perverseness. 

During the spasmodic action which, in the majority of cases, has 
to a critical observer the appearance of being partly voluntary, there 
is apt to be a singular perverseness of moral and intellectual mani- 
festations, which was on a certain occasion very graphically expressed 
by a clerical friend in speaking of a patient, by saying that she 
" seemed to be actuated by an evil spirit." In the midst of great 
suffering, patients not unfrequently try to bite and otherwise wound 
those who endeavor to restrain their violent agitation ; they attempt 
to throw the covering from them with the apparent object of expos- 
ing their person, or say some very perverse things. At other times 
they attempt to imitate the symptoms of some grave organic affection^ 
One patient, by heaving up the lower part of the chest spasmodically 
at rapidly succeeding intervals, induced her friends to think that she 
had violent palpitations of the heart, and therefore must be the sub- 
ject of cardiac disease ; she also imitated throbbing of the temples by 
spasmodic contractions of the temporal muscle. When this throbbing 
of the temples was very violent, I requested her to hold her mouth 
open so as to relax those fibres, but she looked up and said very 
wicked things, and became contemptuously calm. A request to hold 
her breath when the palpitations were violent, induced her to act in the 
same way, and caused an instantaneous cessation of them. The great 
peculiarity in these spasms has always seemed to me to be a guarded 
cunning, a deceitful and perverted consciousness. To a close observer 
this is always easily detected. By using the foregoing epithets descrip- 
tive of the peculiarity of this kind of hysterical phenomena, I do not 
wish to be understood as saying that deceit, cunning, etc., are indica- 
tions of freedom from disease on the part of patients who are thus 
affected. I think this is not usually the case, but that they are the 
result of the morbid state of the mind and body. The spasmodic 
action of the muscles is not contemporaneous in the corresponding 
extremities, as in epileptiform hysteria or epilepsy, but is so irregular 
as to move the body in many different directions instead of giving to it 
frequently repeated similar motions. 

Syncop a I Convu Isions — Hystero-Ep ilepsy* 

There is a singular variety of semi-convulsions, or syncopal con- 
vulsions, which I have often noticed, and I do not remember to have 
observed in any other connection. They occur very frequently after 
they have once seized the patient, as often as three or even six or eight 



MOKAL AND MENTAL DERANGEMENT. 357 

times during the twenty-four hours. They take place in the daytime 
or at night, during the sleeping or waking condition, and do not seem 
to result from any particular excitement at the time. If the patient 
is sitting and talking, or is engaged in work, she suddenly ceases and 
slowly sinks down to the floor; she turns her head to one side, almost 
ceases to breathe, becomes pale and trembles, sometimes very gently, 
sometimes violently. This state lasts only for a few seconds; she 
arouses, looks about confusedly, and, although she knows she has had 
a fit, as her friends call it, she does not remember distinctly anything 
which passed during the time. As these attacks become chronic, they 
may be attended with very slight convulsive movements, frothing at 
the mouth, and sequential somnolence ; but, ordinarily, this is not the 
case. If the patient is attacked in the night while asleep, unless some 
person observes the attack, it will not be known to have occurred, the 
patient being unconscious of it. There is generally, however, move- 
•ment enough to awaken anybody who may be in the same bed with 
the patient. In all cases of this kind I have noticed great impair- 
ment of memory, particularly of recent occurrences. There is not 
usually any severe pain in the head or spinal centres ; there is, in fact, 
no prominent painful circumstance apparently connected with the 
case. Patients having such paroxysms are generally worse at or near 
the time of menstruating ; but sometimes they are quite exempt from 
them at this time, but have them not long after the menstrual conges- 
tion is over. 

Moral and Mental Derangement. 

No more constant derangements, perhaps, occur than are observed 
in the mental and moral qualities of the patient. The patient loses 
the complete control which she has been in the habit of exercising 
over her emotions, and finds herself becoming despondent, fretful, 
suspicious, and unsteady in her purpose : whimsical, having desires 
not before experienced, indulging in thought and feelings toward her 
friends which in her former da}^s she did not entertain. She will often 
call herself a changed woman. If the source of irritation is not dis- 
covered and removed, she loses her strength of will entirely ; and, 
instead of her moral feelings being guided by her will under the in- 
fluence of a sound judgment, she exhibits indecision, and wavers in 
matters about which she heretofore had no difficulty in making decision. 
She finds herself giving way to peevishness to a frightful degree ; no- 
body can please her. In place of her usual satisfaction in the atten- 
tion of her friends, she finds fault with their efforts to make her com- 
fortable. Sourness, moroseness, jealousy, carelessness, timidity, and 
peculiar perverseness change her nature entirely. Sometimes one class 
of ideas will seize her whole faculties, and she will scarcely think or 
talk of anything else. She has no patience with anybody who will 



358 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

not listen to her, and believes everybody to be her enemy who cannot 
sympathize with her in her imaginary troubles. The different phases 
of mental and moral troubles under which the patient labors are al- 
most innumerable. As will be seen, this state of things closely borders 
on insanity, and there is no doubt that insanity is often the result of 
uterine irritation in patients who are hereditarily predisposed to it. 
I think I have seen cases of insanity that were excited into activity 
by the great nervous irritation connected with uterine disease. But 
in place of this steady deviation from her natural mental condition, 
the patient may generally be sane, and show an abnormal state of 
mind only when circumstances occur which are likely to excite her, 
when she loses all control and indulges in excessive anger. Some- 
times, in a fit of despondency or melancholy, she contemplates or even 
attempts suicide. Or, if her sense of wrongs weighs heavily upon 
her, and no means of redress shows itself, she thinks seriously of 
fleeing from what she fancies is the cause of them. Still another sort of 
paroxysm exhibits acts of a depraved and indecent nature, so disgust- 
ing as to shock the witnesses of them, and in her recollection of them 
to mortify her exceedingly. The common hysterical paroxysm of 
crying without a sufficient cause, the indulgence in unbecoming and 
unseemly levity, rapid alternations of despondency and hope, need 
hardly be mentioned, from their familiarity to every observer. When, 
in reference to such unbecoming exhibitions, patients are kindly re- 
monstrated with, they will, in general, acknowledge the impropriety 
of them, but will end with saying, " I cannot help it," which is the 
unanswerable and, doubtless, truthful exposition of their mental con- 
dition. Neglect of duty in all the relations of life is one of the phases 
of their mental state. Sometimes a wilful selfishness, caring for noth- 
ing but what they fancy will make them happy or conduce in some 
way to their interests, absorbs their whole mind and governs all their 
actions. At times there is an intelligent appreciation of the impro- 
priety of their actions. 

Cephalalgia. 

Cephalalgia, in some form, either partial or general, is a very com- 
mon attendant upon the nervous susceptibility of uterine patients. 
It is often general ; the whole head seems to pulsate and thrill with 
terrible pain, rendering the patient almost frantic with the intolerable 
aching. In a few hours it subsides, leaving the nervous energies pros- 
trate for a short time, but otherwise the patient is free from all pain. 
This subsidence would not be complete if the cephalalgia were any- 
thing but nervous pain in the head. The general cephalalgia is often, 
but not necessarily, attended by nausea and vomiting, or other sto- 
machic, hepatic, or intestinal disorders, and may be relieved, when 
that is the case, by emesis or an alterative cathartic. This is what is 



CEPHALALGIA. 359 

commonly called sick headache. The most frequent forms of pain in 
the head, however, are partial, and confined to some particular part ; 
as hemicrania, confined to the whole of one side, or a lancinating pain 
in the temple, brow, or eye. All these are very common pains in 
uterine disease ; but persistent or frequently recurring pain in the 
occipital region, or on the summit of the head, is nearly pathogno- 
monic of uterine disease. It is almost invariably the case that a 
woman has chronic uterine disease if she complain of persistent pain 
in either of these regions. The occipital pain I have observed in this 
connection much oftener than the pain on the top of the head. It is, 
ordinarily, a dull aching, that completely unnerves the patient and 
renders her unfit for her duties for days together ; it is usually very 
persistent, in some patients being almost constantly present, but in 
other cases only occurring once a month, ordinarily at the menstrual 
period. The pain on the top of the head is described generally as a 
burning pain ; patients complain that they have all the time a hot 
place on the top of their heads. This pain is probably more constant 
in patients that have it than any other about the head. I have ob- 
served that when patients suffer greatly from pain in the head, they 
complain less of suffering which is more directly referable to the 
uterus than when any other symptom seems to predominate. Indeed, 
I have met with patients who were martyrs to these excruciating head- 
aches who did not complain of anything which pointed directly to 
the uterus as the origin of their sufferings, and yet upon examination 
that organ was found ulcerated and inflamed ; and when these con- 
ditions were cured by appropriate treatment, the headache ceased to 
annoy them. A remarkable instance of this kind occurred to me 
several years ago. The patient came to town to consult me about 
what she called neuralgia. The pain was located in the occiput ; it 
lasted one week in every four (her menstrual week), and when very 
severe she had hysterical convulsions. This took place at almost 
every recurrence of the headache. She had no backache at any time ; 
her menses were natural in every respect, as far as I could gather 
from her history, on which I placed the more reliance from the gen- 
eral intelligence of the patient. She could walk long distances with- 
out inconvenience, had no pains in the hips, groins, or legs ; in short, 
she made no complaint from which I could infer the origin of the 
nervous suffering to be in the uterus, except that the headache was 
sure to come on at the time of menstruation. Her uterus was ulcer- 
ated and inflamed, and after appropriate treatment was cured, when 
the sufferings vanished, and she has since enjoyed complete immunity 
from them. This woman was about thirty years old and in the midst 
of her childbearing period, and it might hence be supposed that the 
uterus would exercise more S3 7 mpathy than at any other time of life ; 
but, as the following case will show, this is not the fact : Mrs. , 



360 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

forty-nine years of age. had ceased to menstruate three years before I 
saw her, but was subject to the roost excruciating headache every six 
or seven days, each attack so prostrating her that she would scarcely 
recover from one before the next would appear. She had some back- 
ache and inconvenience in walking, but these symptoms scarcely 
attracted her attention amid the terrible sufferings caused by her head- 
aches. Six months' treatment addressed to the uterus alone sufficed 
to remove all this great trouble and render the woman comfortable 
and capable of her duties in life. The overwhelming influence of 
this terrible cephalalgia on the nervous system seems to occupy so 
completely the capacities of it that minor pain is unheeded, and no 
cognizance is taken of the sufferings of the less sensitive but inflamed 
and mischief-making uterus. 

Affections of the Spina! Cord. 

The spinal cord seems to partake very much of the sensitiveness 
of the nervous system, probably more so than the brain. Pain in 
some portion of the spine is almost universally present in uterine 
disease, but is most common in the sacral and lumbar regions. Pain 
is so general in those regions that it has come to be regarded as neces- 
sary, in the estimation of very many persons, to establish the probable 
existence of this affection. The pain is fixed and almost constant, 
but aggravated by anything that excites the uterine vascular system, 
as standing or walking for a long time, lifting or jumping, or sudden 
emotions. Fright, anxiety, or anger, as the patient says, " flies to 
the back " and aggravates the pain. It is especially apt to be worse 
during the menstrual congestion. Sometimes walking so much in- 
creases it as to incapacitate the subject for that kind of exercise. An 
expression often made use of to signify sensitiveness of the back, is 
" weak back." Women will say, " I have not exactly pain in my 
back, but it is so weak that I cannot move on account of it, or can 
hardly stand, or cannot arise from a stooping posture." The pain 
may be fixed in any part of the spine. I have a patient whose back- 
ache is at the junction of the dorsal and lumbar regions. In connec- 
tion with these pains there is often tenderness in the same region, so 
that pressure causes great complaint. The pain is not only increased 
in the part pressed upon, but it sometimes darts along the nerves 
around the body. 

Hyper sesthesia. 

Akin to pains in various parts is hyperesthesia without inflamma- 
tion ; great sensitiveness of particular parts. Tenderness of the scalp 
is often complained of. The whole surface of the head is so tender 
as to require great care in dressing it, and no pressure can be toler- 
ated without an effort. Of a similar nature is tenderness along the 



EXTENSION OF INFLAMMATION TO THE BLADDER AND RECTUM. 361 

spine. The different spinous processes in some sections of the column 
cannot be touched without giving the patient great suffering. Pres- 
sure upon these tender vertebrae sometimes causes pain to shoot along 
the spinal nerves, passing out of the intervertebral foramina in the 
neighborhood. There is occasionally, also, general tenderness of the 
abdomen. 

Anaesthesia. 

Much less frequently there is anaesthesia of some particular parts. 
The patient complains of a want of the ordinary sensitiveness in 
them, or there is a feeling of numbness, which lasts for some days, 
and which recurs so often as to obtain the distinction of a symptom 
of the case. 

The muscular through the nervous system is, in many cases, very 
seriously affected. Cramps and spasmodic action are very frequent 
in particular cases, and they are confined almost constantly to certain 
limbs. They occur more frequently in the lower than in the upper 
extremities. 

Spasms. 

A worse state of things, however, exists when there are general 
spasms of the limbs and abdominal walls and hysterical convulsions. 
They are apparently induced by fatigue, or occur at the time of men- 
struation. The patient, after complaining of severe pain in the stom- 
ach, falls into a state of general convulsions, which lasts from thirty 
seconds to some hours, and subsequently sinks into a state of quietude, 
but not of insensibility. These attacks are usually repeated several 
times and then subside, leaving the patient in the possession of her 
usual physical condition, which is one of nervous misery. 

Sympathetic Pains in the Pelvic Region. 

Painful localities are generally found about the pelvis ; in the in- 
guinal or internal iliac region they are exceedingly common. Imme- 
diately above one of the groins a constant and fixed aching may be 
found, which is aggravated by all the circumstances that increase the 
pain in the back. Most generally there is some tenderness or soreness 
in the part, which is increased by pressure. The pain sometimes ex- 
tends to the hip and side of the pelvis. It is much more frequent in 
the left side, but is often confined exclusively to the right, and less 
frequently it is in both sides alike. In more rare instances the pain 
is centrally situated behind the symphysis pubis. 

Extension of Inflammation to the Bladder and Rectum. 

The patient will often say she has pain in the bladder, or pain 
in the rectum, and believes that these regions are affected. These 



362 SYMPATHETIC OE EEFLEX SYMPTOMS OF UTERINE DISEASE. 

pains, when complained of. art generally very appropriately stated 
to be in the bladder and rectum, and are indicative, for the most 
part, of an extension of inflammation to these two organs. When 
this is the case, pain accompanies or rather is increased by mic- 
turition, or may occur immediately after it. The same remarks are 
applicable to the alvine discharge : during defecation the pain is 
increased, or then only occurs. These pains are not. strictly speak- 
ing, sympathetic, but occur as consequences of the extension of in- 
flammation, and indicate correctly its locality. In the iliac region 
it sometimes extends up the side as far as the mammary region, or 
there may be pain in this latter place not connected with the former. 
The pain may likewise be situated between these localities and be 
independent of any pain in them. 

Affections of the Sciatic and Anterior Crural Nerves. 

Pain in the course of the sciatic, obturator or anterior crural nerves 
is very common in uterine affections of an inflammatory nature. It 
is often so severe and aggravated by exertion as to incapacitate the 
patient for walking. Particular motions cause pain according to the 
nerve affected. When the sciatic is the s°at of pain, sitting down, 
especially on a hard chair, increases it, so that the patient resorts to 
cushions for defence against pressure. Pain in the course of one or 
more of these nerves is often the most distressing circumstance con- 
nected with the case, and it is often treated as neuralgia seated in the 
nerves, while the cause is not even suspected. The pain may occupy 
the whole length of the nerve, or it may be confined to its upper or 
lower parts, or to an intermediate portion of variable length. The 
part of the limb traversed by the nerve may be tender or not ; most 
frequently there is no tenderness. The pain may be fixed, or darting 
and transitory. It may be constant or paroxysmal: the patient may 
enjoy immunity for hours and days, or even weeks, or she may be a 
constant sufferer from them. They are apt. as other pains are, to be 
greater during menstrual congestion than at any other time. The 
pains emanating from the pelvis are not sympathetic, nor are they 
probably reflex ; but they are caused very likely by pressure of the 
uterus, or they may be produced by an extension of the inflamma- 
tion to the nerve-sheaths. 

Muscular Weakness. 

Extreme muscular weakness — I do not mean that which results 
from general debility, but of some particular set of muscles— is often 
present as an accompaniment of uterine disease. This is most frequent 
in the back and lower extremities, not often in the upper extremities. 
It is probably imperfect innervation of the part, or it may be some 



CIRCULATORY SYSTEM. 363 

affection of the muscles themselves. I have been inclined to look upon 
it as partial paralysis, resulting from reflex irritation. More or less 
numbness of the parts exists in connection with the weakness of the 
muscles. 

Circulatory System. 

The circulation and its organs are very often deranged to a distress- 
ing degree. Palpitation of the heart is often troublesome, and patients 
are apt to think themselves the subjects of disease of the heart. We 
are often consulted solely with reference to this symptom, it having 
absorbed the attention and awakened the apprehension of the sufferer 
to such a degree that her other inconveniences were forgotten or over- 
looked. These palpitations are sometimes attended with pain in the 
region of the heart, which occasionally shoots up to the left shoulder 
and down the left arm to a greater or less distance, the distress being 
so great as to amount almost to angina. The palpitation is worse 
during nervous excitement. It occurs generally in paroxysms. We 
meet with instances in which it oftener occurs after lying down at 
night than at any other time. Sometimes it seems to be increased 
during digestion. The sensation of palpitation does not seem to be at 
all commensurate with the increased excitement of that organ, and 
vice versa. I have observed instances in which the patient complained 
of violent palpitation, while the pulse and heart, as far as I could 
judge, were not at all disturbed. In such cases we might say that the 
sensitiveness of the heart was increased until its ordinary motions 
were perceived by the patient. Indeed, the pains and increased irri- 
tability of the organs supplied with the great sympathetic nerve seem 
to result from increased susceptibility or sensitiveness instead of 
organic changes. There is also sometimes a sensation of throbbing, 
as though the blood was passing through the arteries in increased 
quantities, and with increased force in some parts of the system ; this 
occurs mostly about the head, sometimes in the hands and feet, and 
occasionally inside the head, apparently in the brain ; also about the 
genital organs. Great irregularity of distribution of the blood is often 
observable, the hands and feet being uncomfortably cold, and continu- 
ing in that state for twenty-four hours at a time. In connection with 
cold extremities, the head is apt to be hot, or warmer than natural; 
this heat of the head may also be present when the feet and hands are 
of the common temperature. The heat about the head and face is 
sometimes almost constantly present in certain patients, and is the 
source of great annoyance to them. It is apt to be caused by anything 
that excites the person. The heat is greatest and frequently exclusively 
located on the top of the head. I do not think that this sensation of 
heat arises from any other cause as frequently as from uterine disease, 
and I am sure it is one of the most common symptoms in such dis- 



364 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

ease. There is great heat complained of in the back of the head also, 
in many instances, and sometimes it extends along the spine, affecting 
the whole or only sections of it. Burning in the sacrum and loins is 
very common. Flashes of heat and flushes of color in the face and 
head, and even in other parts of the body, are very common and 
annoying occurrences. The power of nervous energy of the heart may 
be impaired to such an extent as to render the patient liable to faint- 
ness from very slight causes — anger, fear, surprise, or even the more 
tender emotions, overcoming the patient very readily. 

Respiration. 

The respiratory apparatus is not so frequently or so severely affected 
as some of the rest of the organization, and yet we often meet with 
some very curious and considerable deviations from the natural con- 
dition of its functions. The constriction about the throat, or the 
feeling as if a ball rose to the throat and obstructed respiration, and 
the feeling as if smoke or dust were in the air which the patients 
breathe, are complaints we hear almost every day. All the sensa- 
tions, or any one of them, may be aggravated to an agonizing degree, 
inducing the fear that the paroxysm may be fatal, and causing the 
patient to suffer for some moments, and sometimes for hours, the 
horrible sensations of impending suffocation. The breathing may be 
spasmodic from painful and unnatural contractions of the respiratory 
muscles. There may also be pleurodynic pains during each ordinary 
effort of respiration. Imperfect respiration, or partial inflation of 
one lung, or of parts of the lungs, occasionally occurs. The modifi- 
cation of the respiratory murmur arising from this imperfect inflation 
of one of the lungs I have observed on several occasions, and not 
without serious apprehension of the result; but in all cases where this 
was the only modification of physical sounds, the patients have done 
well, and the inflation improved as the returning nervous energy of 
the rest of the system was established. The respiration is not often 
hurried as a constant circumstance, but occurs temporarily as the 
effect of excitement from mental or moral emotions. In some cases, 
amid the tumult of nervous excitement during a paroxysm, I have 
seen the respiratory efforts increased to sixty in a minute ; and, occa- 
sionally, these nervous patients constantly have increased frequency 
of respiration. There are cases in which cough is a very constant 
symptom ; it is a peculiar, nervous cough, as a general thing, and is 
excited or made worse by anything that renders the patient more 
nervous. Sometimes it is difficult to distinguish it from the coughs 
which arise from insidious affections of the lungs. It is possible that 
the cough arising from slight lung difficulties may be aggravated 
by the nervousness consequent upon uterine disease. I once saw a 



SYMPATHY OF THE EXCRETORY ORGANS. 365 

patient affected with a peculiar nervous cough, as the effect of uterine 
disease, which sounded like the barking of a small dog, and the sound 
was made at every expiration during the waking condition of the 
patient, except when the mind was intensely occupied. She was an 
intelligent young married woman, about twenty years of age. While 
her whole attention was absorbed, she forgot to cough, but as soon as 
her attention was relaxed, she habitually produced the same sound. 
This had lasted when I saw her six months or more. When she was 
embarrassed by a conversation which related to her case, the sounds 
became much louder and persistent, appearing in perfect synchronism 
with every respiratory effort. I must further add that I did not have 
an opportunity to treat this patient, nor have I heard from her, so 
that I cannot give her subsequent history ; but the rest of the symp- 
toms plainly indicated uterine suffering, and an examination estab- 
lished the fact that she had ulceration and inflammation of the neck 
of the uterus. She had never borne children or miscarried. 



Sympathy of the Excretory Organs. 

The excretory organs also sympathize with the uterus, particularly 
the kidneys. It has been for a long time observed that female pa- 
tients, in a state of nervous excitement, secrete a large quantity of 
urine, which is usually limpid, almost odorless and insipid. These 
qualities are most likely dependent upon the amount of water being 
so much greater proportionately than the salts; these last scarcely 
seem to be present at all. It is extremely dilute urine. Uterine 
patients are very prone to large discharge of limpid urine. This kind 
of alteration in the functions of the kidneys is, doubtless, indirect, 
and does not occur except in connection with a greatly excited condi- 
tion of the nervous system as the medium between the kidneys and 
the uterus. More considerable deviations, however, are apt to take 
place; the salts are likely to be increased in quantity compared to the 
amount of water ; or one sort of the salts may be greatly over or under 
the proper proportions in relation to the others. The urine may be 
decidedly morbid in its composition. It is probable, too, that the 
deviation is secondary to derangements of the stomach and liver, but, 
nevertheless, it is often present. The urine may be highly alkaline, 
or highly acid in reaction, showing the production to an unusual 
degree, of salts having such chemical qualities. The presence of the 
salts in excess, whether of the one kind or the other, is pretty sure to 
produce painful micturition and other disagreeable sensations, as 
burning and smarting in the urethra and bladder. There is no doubt, 
however, that the painful and disagreeable symptoms may arise as 
the more direct effect of inflammation of the uterus when the urine is 
correct in composition ; hence the examination of the urine will be 



366 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

necessary to determine the cause of the symptoms. But the urine 
is often secreted in very diminished quantities in cases of uterine 
disease, and that, too, without apparent general febrile excitement. 
Patients frequently complain of this symptom. Whether there is an 
increase in the excretory functions of the skin at such time I am 
unable to say. The skin is probably not very much affected in its 
excretory capacity as a general thing, but some very curious devia- 
tions have been observed. 

Mammary Bodies. 

More direct are the effects upon the mammary bodies. They are 
often highly excited by uterine disease ; this is no more than would 
have been expected from the close sympathetic relations between these 
organs. Congestion is the most common sympathetic condition. The 
mammse increase in size, become hot and painful as a general thing, 
but sometimes there is no change in their sensible or sensitive con- 
ditions. The appearances are natural, but the patient complains of a 
peculiar and painful condition, not unlike the sensations perceived 
during the suppurative stage of inflammation: but there is neither 
tenderness, nor swelling, nor heat, nor other deviation than the un- 
natural sensation. Sometimes the breasts are really inflamed. The 
lymphatic glands in the axilla, and from the axilla to the border of 
the mammae, in some cases, become affected at the same time; in 
other instances, however, they do not partake in the sympathies of 
the mamma?. They also become tender in some cases when the 
mamma do not seem to be excited. 

I have dwelt so long on these general symptoms, and have made 
so much of uterine sympathies, that I am forced to recall an expres- 
sion made use of in a notice of Professor Hodge's work on Diseases of 
Women, that " if all this is true, it is almost a pity that a woman has 
a womb ;" but I have fallen very far short of mentioning all the sym- 
pathetic evils resulting from chronic diseases of the uterus, and I 
only design this as an outline view of a subject that will fill itself up 
in painfully warm colors in the observation of those who devote them- 
selves to a close study of the diseases of women. While this is my 
conviction, I do not wish to be understood as saying that nearly all 
of the above symptoms will show themselves even in a majority of 
cases ; some of them will be prominent in some cases, others in other 
cases ; and in rare instances we meet with nearly all of them in some 
sufferer, and in nearly all chronic cases we shall find enough to move 
us to commiseration for the ruined health of women thus affected. 
I know there are thousands of my peers in the profession who do not 
see in the foregoing array of symptoms any indication of disease of 
the uterus, and when uterine diseases are obviously coexistent, they 
are not arranged in the order of sequency. This does not shake my 



MAMMARY BODIES. 367 

faith in the facts I have observed for myself, nor disturb my judg- 
ment, formed from an observation of a very large number of cases 
carefully watched through all stages of progress to their termination. 
That all the above symptoms may occasionally be present in cases in 
which the uterus is healthy, I have often observed ; but that they are 
also present as the proximate and remote effects of uterine disease, I 
am well satisfied. Another well-established fact, according to my 
judgment, is, that the direct symptoms referable to the uterus may be 
feebly pronounced, while some, or even a large number, of the sym- 
pathetic disturbances are very prominent ; and, judging by the free- 
dom from pain and other inconveniences in the uterine region, there 
are even cases in which the uterus does not seem to suffer at all. 
These cases are well calculated to mislead us, and to induce the 
opinion that the womb difficulty is of minor importance, and need 
not be the object of solicitude until we get rid of the more troublesome 
and prominent symptoms. We cannot be too careful in our consid- 
eration and management of this class of cases, and while we adopt 
judicious remedial means for the removal of the more afflictino- 
symptoms, we must address ourselves to the disease of the uterus, 
however slight it may appear to be. I have seen too much good 
result from the observance of this direction not to dwell with emphasis 
upon its importance. The cure of the uterine disease will be a valu- 
able diagnostic measure in such cases. Not only may there be a 
great difference, or want of correspondence, in the severity of the 
local and general symptoms, but in many cases in which the general 
symptoms have almost made a wreck of the health and happiness of 
the patient, the local inflammation and ulceration will be found upon 
examination to be trifling in amount and degree. The inflammation 
may be very slight and the patient suffer very greatly from it, either 
generally, or locally, or both ; or the ulceration may be extensive and 
the inflammation very considerable, and yet the patient hardly be 
sensible of any inconvenience whatever from its presence. This state- 
ment will be confirmed by careful observers in this field of research. 
This, however, will prove a stumbling-block to those who entertain 
the opinion that uterine disease is of small importance in the consid- 
eration of woman's ailments. They seem to think that there is of 
necessity an exact and invariable seeming correspondence between the 
magnitude of cause and effect, and they point to these cases and say, 
the symptoms were present, but a very trifling, if any, uterine disease 
showed itself upon examination ; or, they will say, there was great 
ulceration, but the patient did not suffer from its presence, at least 
not in proportion to the amount of local disease. I need not particu- 
larize instances in which other diseases are comparatively latent, or 
cases in which the symptoms are unduly severe compared to the 



368 SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. 

amount of actual disease, as they will suggest themselves to every 
intelligent practitioner. 

But, recurring to the sympathies of the uterus, we find that while 
some patients are not affected at all by pregnancy, and others favorably 
affected, their health being better then than at any other time, that 
some absolutely perish on account of the functional derangements 
inaugurated by pregnancy ; and, as is shown on a former page, organic 
diseases are not unfrequently lighted up. We shall probably always 
be at a loss to understand precisely this difference; but there can be 
no doubt that it is more on account of constitutional differences than 
local ones. The concatenation of sympathetic influences may be 
caused by the greater susceptibility of the organs secondarily affected. 
In fact, the only mode of accounting for it is by supposing this in- 
creased susceptibility. I am convinced that this great but inexplicable 
diversity of sympathetic effects is as likely to result from uterine 
disease as from pregnancy. We must, therefore, expect a very great 
range of difference in the extent of sympathetic derangement from 
uterine disease. It is interesting to observe the rise and development 
of the sequences to diseases of the uterus. How far can the uterus 
produce a direct effect in creating this large amount of sympathetic 
disorder? Are most of the symptoms produced by the direct sympa- 
thetic relation of the uterus to other organs, or does the diseased 
uterus first affect some other more influential organ detrimentally, and 
then this last the organism generally? I am inclined to think, from 
a large observation, that the uterus has close sympathy with only a 
few organs, and no one probably is so powerfully affected by it as the 
stomach. It is the first organ affected in pregnancy, being brought 
into a morbid condition in a very few weeks. The well-known, power- 
ful, and almost universal sympathetic influence exerted by the stomach 
upon other viscera is sufficient, when it is diseased, to account for the 
great variety of subsequent symptoms. The stomach is the great 
centre from which radiate abdominal, thoracic, cerebral, and spinal 
disturbances almost ad infinitum; and there can be no reasonable 
doubt that it is an active agent in originating the disturbances of the 
great vital organs. The subject of the sympathetic influence of the 
uterus then becomes the more interesting and important, from the 
fact that a very slight deviation from its ordinary condition arouses 
the most influential of all the organs to a state of disease, which de- 
presses the functional energies and increases the susceptibilities of 
almost all the rest of the organism. In addition to the chain of sym- 
pathetic susceptibilities produced by this state of the stomach, fre- 
quently the digestive powers of that organ are impaired or perverted, so 
as to supply the chyme in deficient quantities or in deteriorated 
quality, and in this way injuriously affect the composition of the blood, 
inducing anaemia or oligsemia. Imperfect nutrition will follow, as a 



PAIN IN THE SACRAL OR LUMBAR REGION. 369 

matter of course, in the one case, and perverted nutrition in the other, 
so that emaciation or obesity will be ordinarily present. Another 
organ, probably, in direct sympathy with the uterus is the cerebellum, 
as it seems to me to be as frequently affected as the stomach. The 
mammae are, of course, in direct sympathetic relation with the uterus, 
and yet they are not uniformly affected in all cases when the uterus is 
very seriously diseased. I do not believe that we are able to say at 
present whether there are other organs that come directly under 
uterine influence. A proof of the powerful and very ready effect upon 
other organs, of irritation of the uterus, may be found in the fact, that 
very often when the patient is in a condition of comfort, so far as her 
general suffering is concerned, an application of nitrate of silver to a 
morbid os uteri will give her excruciating pain in the head, render her 
exceedingly despondent and irritable, and very much aggravate the 
symptoms with which she is affected. This I have so often observed 
to be the case that I cannot but regard it as one of our diagnostic 
means. After such an application, the patient will generally com- 
plain of an aggravation of the general symptoms, whatever they may 
have been, and say that all the pains are made worse by the applica- 
tion of the caustic. When an organ has been the subject of irritation 
or functional derangement for along time, in consequence of sympathy 
with the uterus, it may become the subject of organic disease, which 
may continue as an independent affection of, perhaps, a dangerous 
character ; or, if organic has not succeeded to functional disease, the 
power of habit, which is so frequently thus engendered, will perpetuate 
morbid action for an indefinite period after the cause of it has been 
removed. 

LOCAL SYMPTOMS. 

Pain in the Sacral or Lumbar Region. 

Pain in the sacrum is one of the most constant, and when persist- 
ent indicates, with a good deal of certainty, disease of some kind in 
the pelvis. The pain in this region, caused by the diseases of the 
uterus, is ordinarily central, being in the middle of the sacrum at its 
lower extremity. It is sometimes at its upper extremity, or it extends 
the whole length of the bone. Not unfrequently a painful spot may 
be found on one side, over the sacro-iliac junction. Some patients de- 
scribe the pain as if a bundle of nerves were pulled upon from the 
inside of the sacrum, and others describe it as an aching or burning 
pain. Accompanying the pain in the sacrum is often a sense of sore- 
ness upon pressure, an inability to sit with comfort, on account of the 
tenderness of the lower part of the sacrum. 

24 



370 LOCAL SYMPTOMS. 



Pain in the Loins. 

Pain in the loins is probably not so common as that in the sacrum, 
but is quite as various in its nature. Very frequently there is great 
weakness in the loins, so great in degree sometimes as to prevent the 
continuance of the erect posture for any length of time. I have had 
a number of patients who were unable to stand long enough to dress 
their hair on account of a weak back. 

It is remarkable that patients often feel this weak back more when 
standing than when walking ; and the}^ are sometimes able to walk a 
distance without any great inconvenience, but as soon as they stop, the 
weakness is apparent to a distressing degree. 

i 

Inability to Walk. 

Ordinarily the weakness disables the patient for walking. The pain 
in the back is almost always increased by walking or standing, and 
on this account the patients avoid being on their feet, although the 
back is strong enough. But there are many patients who have severe 
disease of the uterus, who do not experience any of the inconveniences 
in the sacrum and loins already described ; but some of them are very 
generally present. 

Great pain in the back, closely resembling that arising from a dis- 
eased uterus, is also caused by hemorrhoids, prolapse, or inflamma- 
tion of the rectum. The pain caused by diseases of the rectum, I 
think, is much more frequent on the left side of the sacrum and in 
the left nates or hip than in a central position ; in fact, I have come 
to regard pain, confined to the left nates and hip, as indicating, with 
considerable probability, rectal disease, and I always inquire into the 
functions of that organ when such pain is present. It differs in po- 
sition from the pain in the iliac region, so common as the result of 
uterine disease. It is situated near the sacrum, and more in the side 
of the pelvis than the latter. 

Pain in the Iliac Region. 

Pain in the iliac region is very common. In frequency it is next to 
pain in the back. The pain is commonly situated a little anterior to 
the superior spinous process of the ilium, and below the level of it. 
It is not referred to the iliac bone, or fossa, but to a place a little above 
the groin. We often meet with it on both sides, but much more 
frequently on one only ; on the left side much oftener than on the right. 
Dr. Dewees considered pain in the left groin, or a little above it, as 
almost diagnostic of prolapse of the uterus. It is certainly very fre- 
quently indicative of inflammation of the uterine cervix. 



LEUCORRHCEA. 371 

Soreness in the Iliac Region. 

This pain is generally accompanied with soreness upon pressure, 
and sometimes there is soreness upon pressure when there is no con- 
stant pain. Walking, standing, or riding generally increases it. A 
severe shock or strain from lifting will sometimes cause pain suddenly 
to appear in this region when it had not before been observed. 

Pain in the Side, above the Ilium. 

Instead of the pain situated as here described, there is often pain 
higher up in the side, or in the iliac fossa, or along the crest of the 
ilium, and even midway between the crest andribs of the side. These 
pains are not in the ovaria, although they seem to point to the ovaria 
more directly than to the uterus ; and are by some regarded as a symp- 
tom arising from ovarian inflammation. Dr. Bennett admits that it 
may be a sympathetic painful condition of the ovary. It is not ma- 
terial whether this is true or not; it is certain that it is very frequently 
present in uterine disease, and is almost invariably cured by remedies 
addressed to the uterus instead of to the ovaria. 

Weight, or Bearing-down Pain, or Uterine Tenesmus. 

Another indication of uterine disease, of less frequent occurrence, 
is a sense of weight in the loins or pelvis. This sense of weight is 
experienced in the loins and iliac regions more frequently than else- 
where ; but it is often felt at the pelvis, and oftener in the perineal 
and anal regions. Patients express themselves as feeling a heavy 
weight dragging upon the back and hips, and others feel as though 
the insides were dropping through the vagina. Occasionally we meet, 
with such urgent uterine tenesmus that the patient is obliged to keep 
the recumbent posture in order to enjoy any comfort. In such cases 
the patient in the erect position cannot resist a constant desire to. 
" bear down," resembling the tenesmus of dysentery. This sensation 
is sometimes more distressing than any other symptom,, and obliges 
the patient to desist from walking. 

Leucorrhcea. 

Leucorrhcea is one of the symptoms usually relied upon as an evi- 
dence of disease of the uterus. In the healthy condition of the uterus 
and vagina there ought to be no discharge ; the vaginal canal is 
merely moist, and no mucus should make its appearance externally. 
When the mucous membrane is temporarily excited, there is more 
than ordinary secretion ; but it ceases as soon as the cause of excite- 
ment passes. 

We should a priori expect increased vaginal discharge to be ac- 



372 LOCAL SYMPTOMS. 

companied with some form of disease, especially when it continues 
for more than a few days. Our knowledge of the discharge from 
mucous membranes lining the cavities elsewhere will afford us enough 
data to confirm these views. We do not expect to see a constant flow, 
however moderate it may be, from the male urethra when it is per- 
fectly healthy ; and we take gleet as an evidence of chronic urethritis, 
and it is generally the sequence of an acute attack of that disease. A 
constant discharge from the nose is an evidence also of more or less 
disease. It is just so with the vagina. The indications from leucor- 
rhcea are derived from the color or consistence of the discharge, or 
both. The discharge from the vagina, resulting from mere excite- 
ment of the vaginal crypts, is thin, glairy, and not very tenacious. 
It is ordinarily acid in reaction. There is no color, and but little 
consistence to it. When a moderate excitement of the internal mu- 
cous membrane of the neck of the uterus produces a discharge of 
mucus, sufficient to appear at the orifice of the vagina, the discharge 
is white, not unlike milk, and when examined closely, will be found 
to consist of minute coagula swimming in a little clear fluid. When 
the mucus flows from the mouth of the uterus it is thick, and resem- 
bles very closely the albumen of an egg, and is alkaline in reaction. 
When it passes into the vaginal canal, it meets with the acidity of 
the vagina and is coagulated, and the whole changed from a colorless 
translucency to an opaque white. The reason that the coagula are 
small and so numerous may probably be found in the fact that the 
mucus arrives in the vagina in such small quantities ; each coagulum 
represents a minute drop of mucus, changed in quality. As, how- 
ever, the mucous membrane of the vagina furnishes only a small 
quantity of acidity, when this alkaline discharge from the cervix is 
copious it soon neutralizes the vaginal acid, and passing through this 
cavity unchanged, appears at the external parts possessing its charac- 
teristic qualities. We then hear the patient complain of a tenacious 
albuminous leucorrhoea; she will nearly always compare it to the 
white of an egg, but state that it is more tenacious. Unless the 
quantity is considerable, the mucus from the internal cervical mem- 
brane does not appear at the external orifice unchanged, but passes 
into this curdled condition. There is often a considerable quantity 
of this creamlike leucorrhoea in the whole length of the vagina, and 
hence it has been supposed by many that this is the vaginal mucus 
in its natural condition, and they have called it vaginal leucorrhoea. 

Amount of Leucorrhoea not always Proportioned to Extent of Disease. 

The abundance of this discharge is no criterion by which to judge 
of the amount of disease or its intensity, but it will scarcely remain 
colorless after the integrity of the membrane is invaded. When the 



BEARING DOWN NOT ALWAYS CAUSED BY DISPLACEMENTS. 373 

albuminous fluid appears at the orifice of the vagina, there is per- 
sistent cervical disease almost of a certainty. 

Yelloiv Leucorrhcea, when there is Abrasion or Ulceration. 

The thick, white, or egg-like albumen will be mixed, when there 
is ulceration in the cervix, to a greater or less extent, with pus, so 
that it will be stained yellow; if the quantity of ulceration is consid- 
erable and its surface is producing pus, the yellow will preponderate 
in the color, and sometimes the whole of the production becomes yel- 
low. The yellow color may be in streaks through it, or intimately 
mixed with it, so as to stain it uniformly , or the pus may be mixed 
with the white, creamy secretion found in the vagina. Pus may be 
mixed with any of the varieties of leucorrhcea, and impart to it its 
tint more or less completely. 

How is the Pain Produced f 

How are the local, painful symptoms produced? Is the pain in 
the groin or ilium caused by prolapsus, and traction on the broad or 
round ligaments? I think not. Pain and sensitiveness in the ilium 
are so frequently present — when I cannot detect any kind of displace- 
ment, and so generally disappear when the inflammation or conges- 
tion is cured— that I am convinced displacement is not necessary for 
their production. They are of that character of pains which range 
themselves in the category of the vague, yet indispensable term, sym- 
pathetic, or, of the not less fashionable, yet equally indefinite term, 
reflex; and are perhaps in the ovary. 

Bearing Doiun not always Caused by Displacements. 

The sense of weight or bearing down in the pelvis is one about 
which there would, from its nature, seem to be no doubt as to its 
origin being in displacement. It gives the patient the idea that the 
womb is bearing with unusual weight on unusual places, viz., the 
perineum, the rectum, or the bladder; and yet, in a great many in- 
stances, we shall fail to detect any deviation from the natural position 
of that organ ; and, as soon as the inflammation is cured, the symp- 
tom vanishes without any treatment with reference to displacement. 
How can we account for this symptom? I think its explanation 
may be found in the fact that the pelvic organs, on account of the 
general pelvic, vascular turgescence, are unusually sensitive and re- 
ceive painful impressions from contact, which in the absence of these 
conditions, would have no effect in causing inconvenience of any kind. 
Moderate prolapse, retroversion, or other displacement, when unat- 
tended by congestion or inflammation, may exist for a long time with- 
out giving rise to any disagreeable sensation whatever. When the 



374 LOCAL SYMPTOMS. 

uterus is slightly displaced, with considerable pain and sense of weight 
accompanying this condition, the displacement is commonly considered 
to be the cause of the distress. When, however, the uterus occupies 
a normal position, and a sense of weight and pain still exists, it is 
regarded by most practitioners as the result of an "irritable uterus." 
That the uterus is sensitive, "irritable," if the term suits better, there 
is no doubt; but that it is ever so without congestion or inflammation 
I do not believe. 

Severity of Suffering not Commensurate icith Amount of Disease. 

The great error in the estimate of the importance of uterine inflam- 
mation is in endeavoring to measure the amount of inflammation by 
the severity of suffering, in assuming that because the woman suffers 
a great deal there must necessarily be extensive inflammation or 
ulceration. I believe I have seen more nervous prostration, more 
keen suffering, and have heard louder complaints from a small amount 
of endocervicitis than from extensive and obvious external ulceration. 
Pelvic congestion and increased sensitiveness of the viscera contained 
in the pelvic cavity, caused by a small amount of persistent inflam- 
mation in the neck of the uterus, calls into action, in an exaggerated 
and intensified form, all the sympathies which are excited by the 
uterus in its physiologically congested condition, and its persistence 
wears the more upon the general organism on account of the increased 
sensitiveness produced from day to day by virtue of its chronicity 
alone. It is anticipating what I shall say in the chapter on Prognosis, 
to state that endocervicitis is not only more difficult to cure, but more 
destructive to the health and happiness of the patient than inflamma- 
tion and ulceration external to the os. Indeed, we often find cases of 
extensive ulceration very apparent through the speculum, and conse- 
quently entirely unmistakable to the most careless observer, which 
produces less inconvenience than an amount of endocervicitis so small 
as to escape the attention of any but an experienced gynecologist. 
This fact is perplexing, but the knowledge of it will cause a proper 
appreciation of what is apparently a trifling matter. 

Effects on the Functions of the Uterus. 

Having given the foregoing sketch of the general and local symp- 
toms of congestion and inflammation of the uterus, I purpose to 
glance at the effects produced on the functional action of that organ. 
The first function assumed by the uterus and the last it continues is 
menstruation. It becomes a matter of interest to the physician to 
ascertain the cause of deviations in a function so persistent, so general, 
and so important to the health of woman. As hyperemia is the 
cause of injurious and even destructive tissual changes and of func- 



EFFECTS OF PARTIAL CLOSURE OF OS UTERI ON MENSTRUATION. 375 

tional aberrations in the vital organs much more frequently than any- 
other pathological condition, so I think that the functional aberra- 
tions of the uterus particularly depend much more frequently upon 
it than upon any other cause. 

Pain during Menstruation. 

Pain during menstruation is not necessarily attended by deviation 
from the normal monthly flow. That there are varieties of dysmen- 
orrhea or painful menstruation, with unusual quantities and extra- 
ordinary kinds of discharge, is true ; but, in many instances, the 
discharge, though accompanied with pain, is right as to its character 
and quantity. 

Kind of Pain attendant upon Uterine Inflammation. 

The kind of pain attendant upon uterine inflammation is, for the 
most part, the same in quality, but varying in intensity. It is a con- 
tinuous sore pain, with heat in the parts, sometimes so slight as to 
give the patient very little inconvenience, and it varies from this to 
pain of great severity. The pain is at times sufficient to cause the 
patient to keep her bed for several days, and sometimes for the whole 
period of the menstrual flow ; occasional^ it amounts to agony, pros- 
trating her by a paroxysm which may last for hours, or even several 
days. 

Cramping Pain. 

Instead of this continuous sort of pain, of varying intensity and 
duration, there are less frequently painful throes " coming and going," 
like labor-pains or after-pains. This kind of pain is often mistaken 
for colic. They are often very severe, and may last a few hours or 
several daj^s. They may depend on some substance contained in the 
uterus, as shreds or membranes of fibrous exudation, and cease at 
their expulsion. But oftener no such cause can be discovered in the 
evacuations ; nothing can be found but fluid blood, or coagula evi- 
dently formed in the vagina. In other cases the os uteri internum is 
small, and does not readily admit the passage of the uterine sound. 

Effects of Partial Closure of the Cs Uteri on Menstruation. 

Many practitioners believe that this condition of the os internum, 
by preventing the ready flow of the blood, causes it to accumulate 
until the quantity is sufficient to arouse expulsive efforts for its ex- 
trusion. In a large majority of cases I have had the opportunity of 
observing, there was no coarctation ; and in several of the worst cases 
I have met with, the os internum allowed the sound to pass with so 
much freedom that I could not distinguish its locality. It is also true 



376 LOCAL SYMPTOMS. 

that in many cases in which the os externum was not larger than a 
small pinhole, the patients menstruated without any pain whatever. 
By far the most frequent causes of dysmenorrhea from obstruction I 
meet with are in connection with flexions of the uterus. I can easily 
understand that a sharp curvature in the cervix, or at the junction, 
will prevent the free efflux of the menstrual fluid. In such cases the 
pains resemble labor-pains, and are, doubtless, of the character of 
uterine contractions. The pain from inflammation may occur at any 
time during the menstrual flow, and before and after it. Not unfre- 
quently a paroxysm of severe pain, lasting several hours or a day, 
warns the patient of the approach of the discharge, and subsides sud- 
denly and completely, or gradually and incompletely, as soon as the 
discharge is fairly established. Frequently the pain continues during 
the whole time of menstruation, beginning shortly before or synchro- 
nous with the discharge, and subsiding with it, though in occasional 
cases it continues after it. We sometimes meet with patients who 
begin to menstruate without any suffering, but who have pain during 
the flow, or after its discontinuance. I think that a majority of 
patients affected with uterine disease have some pain during menstrua- 
tion ; but there are some who have none whatever, and pass through 
their period with little or no suffering. 

Manner of the Flow modified by Inflammation and Congestion. 

The manner of the flow is often modified. Instead of the continu- 
ous flow, commencing moderately, gradually increasing, and then as 
gradually declining, every manner of deviation almost may exist. 
With some, the discharge begins naturally, increases very rapidly, 
until at the end of twenty-four or thirty-six hours an average amount 
is lost, and then the discharge suddenly declines and ceases, or con- 
tinues in very moderate quantity for a time longer, and gradually or 
suddenly stops. With others, the flow may begin and proceed natu- 
rally for a day or two, cease for one or two days, and then reappear 
and flow freely for a sufficient time. When menstruation proceeds in 
this way, it is generally attended with pain. These two varieties are 
more frequent than any other. 

Duration of the Flow. 

The duration of the flow may not be affected by it. The flow may 
continue three weeks or the whole month. This, however, is not 
frequent. It does not much affect the periodicity of return, of men- 
strual congestion and effort ; but it is not unusually the case that we 
cannot distinguish the discharge which attends ovulation from the 
hemorrhage which proceeds from an ulcerated surface, as hemor- 
rhagic congestion is so constantly present. We often meet with 



MENORRHAGIA AND AMENORRHCEA. 377 

patients who are so confused by the frequent irregular returns of 
uterine hemorrhage that thej r lose all reckoning as to the time for the 
menstrual return. Occasionally, continuous hemorrhage is present. 
The most frequent deviation from regularity in menstruation consists 
in a slight anticipation of the time of its return. 

Menorrhagia. 

Menorrhagia, or hemorrhage at the menstrual period, is not an 
unusual functional deviation. The hemorrhage is often very consid- 
erable and continues after the usual period has passed by. The 
flooding is usually greater while the patient is in an erect posture, 
and it is greatly moderated by recumbency. Occasionally, however, 
it is not moderated by this means. It would seem probable, a priori, 
that menorrhagia would be the rule with patients affected with uter- 
ine inflammation, but such is not the case. I am not sure that even 
a majority of patients have it. 

Menorrhagia frequent in Endocervicitis. 

I have observed that menorrhagia occurs much more frequently in 
patients when the inflammation occupies the cavity of the neck ; this 
also is the case with painful menstruation. All cases in which there 
has been either great pain or hemorrhage, or both, for they are fre- 
quently coexistent, have been, in my observation, cases in which 
endocervicitis is the principal disease. Menorrhagia is not always the 
result of inflammation of the uterus, though inflammation is its most 
frequent cause ; and in such cases it cannot be cured without first 
curing the inflammation. 

Amenorrhea sometimes Results. 

Amenorrhcea is the least frequent of menstrual deviations as the 
effect of inflammation or congestion of the uterus ; but this inflam- 
mation is frequently the cause of scanty menstruation. It is curious 
to note the manner in which this scantiness occurs. It seems to come 
on after the inflammation has lasted for a considerable time, and is 
almost always associated with sterility. In cases I have watched for 
some time, the organ was atrophied and rendered less vascular and 
erectile ; probably on account of a deposition of fibrin throughout 
the general structures of the uterus. The scantiness is sometimes 
attended with irregularity, which consists in postponement or length- 
ened intervals. I treated one patient for endocervical metritis, in 
whom the uterus did not appear to be, as far as I could measure it 
per vaginam, more than one inch and a half in length, and corre- 
spondingly small in the other dimensions. This patient would men- 
struate sometimes only a day every month, and discharge but half an 



378 LOCAL SYMPTOMS. 

ounce of blood each time, and occasionally the discharge would not 
return for five, six, and even nine months. In early life her menses 
had been regular in quantity, quality, and times, and unattended 
with pain. She was barren, having never conceived, as far as she 
was aware. She dated the beginning of her disease from vaginitis 
during an attack of fever, which occurred two or three months after 
marriage. 

Function of Generation affected by It. 

The great function for which the uterus was formed, that of gen- 
eration, seems very frequently to be disturbed by inflammation of 
the neck of the uterus. Some practitioners think, because a woman 
bears children with frequency, the uterus cannot be much diseased. 
This is unquestionably a mistake. I have known many women with 
extensive ulceration to bear children very frequently, but there is 
always great liability to embarrassment of the function in such cases. 
Conception may be entirely prevented by inflammation, or gestation 
ma}^ be arrested by miscarriage, or labor may be rendered difficult by 
it ; and there is no doubt that many cases of sterility depend wholly 
upon innammator}^ action about the neck. 

Sterility. 

Sterility is attended by different circumstances. Some women are 
sterile their whole lifetime; others, after having borne children to 
the full period and given birth to them, become sterile for years, or 
for the whole of their subsequent life ; others again become pregnant 
soon after marriage, miscariy at an early period, and never again con- 
ceive. In many cases of sterility which I have had the opportunity 
of examining, I have found evidence of inflammation in the cervical 
cavity. Very often the inflammation is confined to this cavity. The 
history of these cases showed that congestion and inflammation had 
existed from the time of menstruation; these were cases in which 
conception had never taken place. In cases of sterility in which 
the women have become sterile after having once borne children, 
ulceration is usually situated around the os, extending upward into 
the cavity of the neck. This is almost certain to be the case if the 
woman has borne several children. When the patient has miscarried 
but once, there is not likely to be external inflammation to any great 
extent ; but if there have been several abortions, the ulceration is apt 
to creep out and manifest itself upon the labia uteri, and sometimes 
becomes very extensive. Although the foregoing statements, with 
reference to the position and extent of ulceration in sterility, will 
generally be found to correspond with the appearances, yet we must 
not be surprised to find pretty extensive ulceration external to the os 
uteri in the originally sterile patient ; and in those who have borne 



CONDITIONS OF THE UTERUS IN ABORTION. 379 

children and become sterile afterward, we shall sometimes find no 
external ulceration. The result of my observation is, that when 
sterility originates in uterine inflammation, it is in that form of it 
known as endocervicitis. Sterility often depends on the condition 
and quality of the leucorrhcea. In many of these cases the secre- 
tions from the vagina are very abundant and intensely acid, so as to 
produce irritation of the external organs. Although the semen is 
diluted and defended from the influence of acid vaginal secretions, 
by mucus of alkaline reaction, yet when these vaginal secretions are 
abundant and possess strong chemical qualities, they may destroy 
the vitalizing influence of the seminal fluid, and thus prevent fructi- 
fication. Or the very thick, tenacious, albuminous fluid, which some- 
times plugs up the os uteri and whole cervical cavity, may prevent 
the ingress of the spermatozoa, which, by their independent motion, 
according to present belief, penetrate the uterus, meet the ovum 
somewhere on its passage to the os uteri, and produce their fructifying 
influence upon it ; and thus is precluded the possibility of effective 
insemination. 

Abortion. 

But conception may readily occur and pregnancy be complete, and 
after gestation has continued for a certain time abortion may take 
place. Abortion is a very frequent effect of inflammation and ulcera- 
tion of the os and cervix uteri. The seat of inflammation or ulcera- 
tion which most frequently induces it is inside the cervical cavity. 
We find some patients who have aborted very frequently and never 
had a full-term child ; others, who have had one or more children, 
but who miscarry every pregnancy afterward ; and again, others who 
miscarry frequently and occasionally go to full term. It is not strange 
that miscarriages should result from this cause ; a priori, miscarriage 
might be regarded as its necessary effect. Nevertheless, many patients 
bear children at term who labor under severe ulceration, and who are 
prostrated by the constitutional sympathies accompanying pregnancy. 

Conditions of the Uterus in Abortion. 

Two general conditions of the uterus exist as the effect of cervical 
inflammation, and are probably the proximate causes of abortion, viz., 
congestion or arterial injection of sufficient strength to cause hemor- 
rhage ; and, perhaps, by means of insinuation of the clots, separation 
of the placenta, or irritability of such a nature occurs that contraction 
and expulsion follow conception ; or, perhaps increased sensitiveness 
of the mucous membrane may increase its excito-reflex influence so 
as to arouse uterine contraction, and thus cause the foetus and mem- 
branes to be expelled. When abortion is caused by congestion, it is 
apt to be ushered in by hemorrhage. The hemorrhage, after con- 



380 LOCAL SYMPTOMS. 

tinning for a varied length of time, from a few hours to several days, 
is followed by uterine contractions. When abortion is the result of 
increased irritability, the first symptom is contraction, with the par- 
oxysmal pains attendant upon it. This continues for a time, when 
hemorrhage and expulsion succeed. When abortion occurs once, it 
is very likely to recur in every subsequent pregnancy about the same 
time, until the disease is cured upon which it depends. While abor- 
tion is very apt to recur in the congestive or hemorrhagic variety, it 
is generally not so exact in the time of recurrence. This variety, 
however, takes place more frequently at the time when the monthly 
congestion is present, while the other is independent of such influence. 
The probability is, that in the congestive variety the foetus perishes 
before expulsive efforts arise ; while in the other the foetus is not 
affected until the contractions have continued long enough to parti- 
ally separate the placental attachments. Whatever doubt, however, 
may exist in all this, there can be no question as to the injurious effect 
produced upon gestation by ulceration or inflammation of the cervix 
uteri. Mr. Whitehead, of Manchester, England, has written a book, 
full of information, almost solely to illustrate this consequence of 
uterine inflammation. 

Effect upon Labor. 

The effect which inflammation of the uterus exerts upon labor is 
not so apparent as upon the progress of gestation. Although I have 
watched patients whom I knew to be laboring under inflammation 
of the neck of the uterus in parturition, I have not been able to per- 
ceive any increase in suffering or tediousness. 

Even when induration and hypertrophy were both of several years' 
standing, no ill effects from them, so far as I could see, attended labor 
either at full term or prematurely. I have observed cases of abortion 
occurring in such patients quite as readily, and with as few trouble- 
some symptoms, as in one whose uterus was healthy. The general 
tissual changes going on in the uterus would lead us to expect this 
in advanced pregnancy, but I confess to some astonishment at having 
seen kindly, rapid, and complete dilatation in abortion at the early 
periods. It is equally singular to see the return of the induration 
after the involution of the uterus is fairly completed. One would 
suppose that the softening accompanying pregnancy would be per- 
manent, and this is usually the case. I have not observed in such 
cases that the abortions were attended with more hemorrhage, or were 
more tedious or painful, than when they occur as the result of some 
transient cause. 

Effects upon the Post-partum Condition. 

Of its effects upon the childbed or post-partum condition, a favor- 
able opinion cannot be given from my observation. A good getting- 



EFFECTS UPON THE POST-PAETUM CONDITION. 381 

up is not to be expected with much confidence in patients affected 
with uterine disease. The most common effect in childbed is retard- 
ation of the processes of involution. The congestion consequent upon 
labor is protracted, the uterus remains larger and more sensitive than 
is usual, so that instead of the organ recurring to its primitive dimen- 
sions and susceptibility in one month, two or more may be required. 
The lochia, instead of subsiding in fourteen or twenty-one days, con- 
tinues for weeks, or even months, after it should have subsided, and 
when it goes off it is apt to merge imperceptibly into leucorrhcea, 
which becomes persistent. Inability to walk or stand without great 
distress is the effect of the size and sensitiveness of the organ. A 
sense of bearing down, or of weight in the ]3elvis, pain in the sacrum, 
down the sciatic nerve or in the hip, harass, the patient greatly, and 
these symptoms pass off so slowly that she is kept in bed an unusual 
length of time. Acute metritis not unfrequently supervenes, or acute 
inflammation of the cellular tissue at the side of the uterus. Phlebitis, 
pyaemia, and phlegmasia dolens are more likely to arise in patients 
who have chronic inflammation of the cervix. 

On the other hand, it is a fact that these subsequent acute inflam- 
mations sometimes operate very favorably upon the chronic affections. 
Instances are not uncommon of patients being entirely cured by the 
effects of gestation and labor upon the tissue of the neck and its 
mucous membrane. We are to hope for this favorable result only 
as a remote probability, because as already stated, the condition of 
the parts is generally left in statu quo, or, if any difference is percep- 
tible, it consists in an aggravation of the disease, and the patients get 
up from childbed rather worse than better. 



CHAPTEK XVIII. 

PATHOLOGY OF HYSTEROPATHY. 

What are the pathological conditions giving rise to such numerous 
and diverse symptoms? 

In answering this question it should be remembered that in con- 
sequence of the nervous and vascular connections and the one great 
function to which they all contribute, physiologically and patholog- 
ically, the pelvic viscera are a unit. 

From the ovaries to the perineum the genital organs are largely 
supplied with the same system of vessels and nerves, and are presided 
over by the same genito-spinal centre, and they all have for their ob- 
ject the same general purpose, — generation. 

In ovulation, menstruation, conception, pregnancy, parturition, 
lactation, and involution they all participate, and are in a continual 
state of change. The rectum and bladder are continually influenced, 
physiologically and pathologically, by the same conditions, and in 
return reflect their own changes back upon the genital organs proper. 

All the genital organs are thus bound together as one great and 
complete system set apart for one grand purpose, — generation ; sub- 
ject to derangements that may begin in any one part or- organ, and 
produce disorder in all the rest. Acting as a whole in the function 
of generation, this extensive and perpetually active system reacts with 
great energy through its spinal centre upon the whole organism. 

I have already in one example quoted from Dr. Tyler Smith — and 
similar cases are continually occurring — shown how vast and potent 
are the sympathetic effects produced by pregnancy upon the system 
at large. 

In a state of disease this great system is as powerful in causing 
morbid symptoms and changes. 

This view of the comprehensive nervous and vascular interde- 
pendence of the pelvic viscera, and their united influence upon the 
whole body, explains how the disease of any one of them may originate 
and perpetuate the general and local symptoms enumerated under the 
terms sympathetic nervous symptoms, hystero-neuroses, genito-uri- 
nary neurasthenia, etc. And we are obliged to give full scope to this 
idea in all our estimates of the very complex functional and organic 
diseases of the female organs of generation, if we would arrive at 
correct indications for treatment. 

The essential pathological conditions of the pelvic organs upon 
which the reflex sufferings of the general system are founded are the 



PATHOLOGY OF HYSTEROPATHY. 383 

hyperemia and the hyperesthesia of those organs. Without increased 
sensitiveness or increased vascularity of them there can be no general 
suffering. This proposition is proven by the testimony of the best 
authors and teachers everywhere. 

The more marked form of hyperesthesia is for the most part con- 
fined to the urethra, vulva, perineum, anus, and coccyx : vaginismus, 
anal fissure, urethral caruncula, coccygodynia. Sometimes there is 
hyperesthesia of the vagina and vaginal cervix uteri. These will be 
described in their proper place. 

In studying the subject from a clinical point of view the practi- 
tioner will find disease of the ovaries or uterus the starting-point of 
all these sympathetic derangements more frequently than all other 
pelvic affections, and consequently it is very important that we should 
have a clear view of their pathology. 

While the ovaries in many respects are paramount in their influ- 
ence on the pelvic organs, it is to diseases of the uterus we must look 
for an explanation of the great majority of sympathetic ailments 
above described. 

Now what is that essential pathological condition of the uterus 
which causes these symptoms? One condition seems to be present 
more frequently than any other, and that is hyperemia. The enlarge- 
ment of the uterus, as well as the hyperesthesia of that organ, gen- 
erally depends upon hyperemia, and the sympathetic influences of 
the uterus are excited through the system of nerves that accompany 
and control the vascular system, — the vaso-motor nervous system. 
Displacements, flexions, and lacerations do not produce any general 
disturbance except when attended with hyperemia. This statement 
is made in a direct or indirect manner by almost all of our best 
gynecologists. 

Dr. Emmet says :* 

11 A version, as has been stated, may exist for an indefinite period without causing 
any disturbance so long as the organ does not prolapse sufficiently to increase the ex- 
isting obstruction to the circulation." 

With reference to lacerations he says : 

u Sometimes the laceration heals while the woman remains in bed after labor, but if 
the surfaces should not heal before she gets up they will soon become the seat of exten- 
sive erosions, which bleed readily. As the uterus increases in size a profuse cervical 
leucorrhcea follows, and the appearance of a frequent show causes the patient to seek 
relief. She will complain of inability to stand with comfort, of a continual headache, 
with pains down her limbs, sometimes irritation of the bladder, and as a rule marked 
nervous disturbance." 



* Principles and Practice of Gynecology, pp. 309, 462. 



384 PATHOLOGY OF HYSTEROPATHY. 

And again on page 467 : 

"The uterus, from increased weight, and while resting on the floor of the pelvis, 
will, by traction on the cellular or connective tissue, obstruct the circulation sufficiently 
to produce not only increased congestion of the organ itself, but also of the neighboring 
tissue." 

These quotations show that Dr. Emmet believes that the effects of 
displacements and lacerations are to produce and keep up hypersemia, 
congestion of the uterus, and through this condition to cause all the local 
and general symptoms. 

The object of all his treatment preparatory to uniting the surfaces 
of a laceration of the cervix is to relieve the hyperemia by giving free- 
dom to the circulation of the uterus and making local applications to 
the erosions. When all of this is done the symptoms subside, and the 
cure of the laceration renders the cure permanent. 

Hyperemia is not often an independent affection. It is, in fact, gen- 
erally the result of some antecedent etiological lesion, and may be 
removed by getting rid of the cause. It does, however, occasionally 
stand independent of any other lesion, and may be cured by measures 
having no other object in view than the removal of the hyperemia. 

Now, what is this hyperemia? There are undoubtedly several 
forms. 1. Active hypertrophic hyperemia, as in pregnancy, the earlier 
conditions of subinvolution, the presence of fibrous tumors, or granu- 
lar degeneration of the mucous membrane. 2. Passive, venous or 
congestive hypersemia, as where the uterus is displaced or flexed, and 
the blood confined to the fundus or other portion of the organ by con- 
striction of the veins, or where effusions around the uterus prevent the 
free outward flow of the blood. 3. Inflammatory hyperemia. These 
are the most common and easily-determined forms, and will serve as 
examples of hypersemia. All these forms may become chronic, and 
all of them, when of chronic duration, produce changes in the fibrous 
structure of the uterus. 

It is impossible for them to remain simple hypersemia, because the 
abundant supply of arterial blood in the active forms of congestion 
produces hypertrophy of some of the tissues that enter into the struct- 
ure of the walls of the uterus, and in others give rise to neoplasms. 

In the passive and inflammatory forms of hypersemia there neces- 
sarily occur fibrino-plastic effusions, which, after coagulating, become 
organized in a low degree, causing not hypertrophy, but induration 
and condensation, which finally cuts off the capillary circulation. In 
these cases the connective tissue formed by this low organization of 
fibrino-plastic effusion supplants the natural structure of the uterus to 
a greater or less degree, and is what I understand by hyperplasia. 

After the uterus is thus changed in structure it is sometimes impos- 
sible to restore it to its natural condition. These indurated uteri un- 



PATHOLOGY OF HYSTEKOPATHY. 385 

fortunately are not deprived of their sensitiveness ; in most cases, in 
fact, there is hyperesthesia, and, as a consequence, they are the source 
of extensive reflex mischief. 

In the inflammatory form of hyperemia there are often circum- 
scribed points of induration in the cervix, in the anterior or posterior 
walls of the fundus, owing to the locality in which the vascularity is 
most protracted or intense. 

After the effusion and induration is established the active inflam- 
matory condition may subside, leaving the part in a state of indura- 
tion and hyperesthesia. Thus we find nodules of hardened tissue, not 
the seat of inflammation, but the consequence of that process. As a 
rule, these nodules may be removed when properly treated, especially 
if they exist in the cervix. The deposits thus occurring frequently 
distort and deform the cervix, rendering one portion more prominent 
than others. 

It should be borne in mind that these conditions do not indicate the 
presence of inflammation, but its effects. They give rise to the same 
sympathetic symptoms and suffering that are noticed in other forms 
of uterine disease. 

It is too narrow a view of the pathology of uterine disease, there- 
fore, to apply the term congestion to all these forms of hyperemia. 
To complete this very cursory statement in reference to the different 
forms of hyperemia, it is necessary to trace somewhat further the 
changes they all may, and generally do, bring about. During the 
progress of all these hyperemie, the mucous membrane undergoes, 
notable changes. One of these changes is the so-called ulceration. I 
use this phrase " so-called " in imitation of those who deny the exist- 
ence of ulceration. 

Now ulcer means a sore, and is defined by Dunglison to be " a so- 
lution of continuity in the soft parts, of longer or shorter duration." 

Is a solution of continuity of the epithelium an ulcer ? Abrasion 
is a term used by some writers to signify the loss of epithelium ; but 
abrasion means a solution of continuity in the epithelium, and is es- 
sentially the same as ulceration. If it suits the reader better to call 
this loss of the epithelium abrasion, I have no objection to the term, 
but I believe it less a reformation in nomenclature than a dispute 
about non-essentials. 

I believe further that abrasion or ulceration, instead of being an 
incident resulting directly from laceration, is an essential effect of the 
impaired nutrition of the mucous membrane, brought about by the 
hyperemie condition of the fibrous structure of the cervix. 

This is in accordance with the teachings of that eminent patholo- 
gist, the late Dr. E. R. Peaslee, in the lectures delivered to his classes, 
and published in the Medical Record for January and February, 1876, 
and most of the recent writers on gynecology. 

25 



386 PATHOLOGY OF HYSTEROPATHY. 

That ulcerations occur in the trophic forms of hyperemia, we have 
the assurance of the late Dr. Cazeaux, who found that a large number 
of pregnant uteri were ulcerated. He says :* 

"According to MM. Gosselin, Danyau, and Costilhes, 'these ulcerations are much 
less frequent than I had supposed, and are met with in hardly more than half the 
cases, while I have observed them in seven-eighths.' In short, therefore, the fungous 
condition of the neck, and the ulcerations, of greater or less depth, which complicate 
this state of the parts near the termination of pregnancy, seem to me to be the con- 
sequence of the active or passive congestion with which the organ is affected." 

So with all the active and passive congestions the integrity of the 
mucous surface of the cervix is affected, and it is the seat of ulceration 
of a greater or less depth. 

Now then I think we must regard abrasions, " granular and cystic 
degeneration," or ulcerations of the cervix, as results of some form of 
uterine hypersemia — trophic, congestive, or inflammatory, instead of 
standing as an etiological condition. 

While I believe the hyperemia of the pelvic organs to be the more 
frequent form of disturbing condition, I am satisfied that there are a 
great many cases of pure neurosis of the genital organs. In these 
cases the genetic element is in the nervous system, and the manifesta- 
tions are morbid exaltations of the sensibility of the parts in which 
the suffering is the greatest. There is no congestion, no inflammation, 
no displacement, or other apparent deviation from the natural appear- 
ances of the pelvic viscera. Yet the patient has pain and sensitive- 
ness in one or all of them, and is the subject of the most distressing 
and extensive array of hystero-neuroses. In such cases, too, there 
may be no deviation from the normal condition except that of pain 
and increased sensitiveness. They are not always even dysmenor- 
rhceal cases. Although not confined to multipara, they are more fre- 
quently found in young girls and sterile married women. In consid- 
ering the subject of the essential pathological conditions giving rise to 
uterine symptoms, we cannot, therefore, ignore the neuropathic forms 
of ovarian and uterine affections. They are too numerous and too 
obvious to escape the attention of the observing gynecologist. 

Mucous Infla mmation. 

As a simple affection, that of inflammation of the mucous tissue is 
quite frequent. Where it coexists with inflammation of the sub- 
mucous substance, we have the increase of size, hardness, and irregu- 
larity of shape combined with the evidence of mucous disease. 

* Pages 456-459, fifth American from seventh French edition. 



ENDOCERVICITIS. 387 

Seat of Mucous Inflammation. 

The inflammation of the mucous membrane may extend from the 
fundus through the cavities of the body and neck to the os, and then 
cover the whole of the vaginal portion of the uterus. This extent of 
inflammation is not very frequent, however, and when it occurs it al- 
most immediately succeeds parturition or abortion, or is produced by 
gonorrhceal inflammation. I have seen it under these circumstances 
oftener than any other. It almost always causes a great deal of distress 
and suffering. 

Probably the most common extension of inflammation is to the mu- 
cous membrane of the cavity of the cervix and body, and a portion 
or the whole of the membrane covering the intralabial portion of the 
os. By far the greater number of instances that have come under my 
observation in practice were inflammation of the membrane around 
the os and inside the cavity of the cervix. I fear that this statement 
represents a fact that has not been generally apprehended by practi- 
tioners. I am disposed to believe that too many physicians have 
failed of success in curing their cases because they have not followed 
up the inflammation sufficiently in the cervix above the os, being 
satisfied with curing that which was visible only, and, in consequence, 
leaving really the most important part of the affection untouched. 

Cavity of the Body of the Uterus. 

Inflammation limited to the cavity of the body of the uterus is not 
common, but I am quite sure that I have met with it in several in- 
stances. Some of these had been treated for inflammation of the os 
and cervix, and cured of this, but the inflammation in the cavity of 
the body was left. Others had not had any treatment for uterine dis- 
ease, so far as I could learn. They had habitual leucorrhseal discharge 
of rusty-colored mucus, very much like the brickdust sputa of pneu- 
monia ; the os externum was very small, and the os internum large, 
as was also the cavity of the body. 

Endocervicitis. 

Endocervicitis alone, or inflammation limited to the cavity of the 
cervix, is, on the other hand, an extremely common form of the dis- 
ease. Not unfrequently this form of inflammation exists without any 
appearance of it in the os or external to it. When inflammation of 
the mucous membrane of the cavity of the cervix alone exists, it has 
certain effects upon the shape and other properties of the neck that 
are apt to attract our attention. Dr. Bennett describes the os as patent 
and the cavity of the neck enlarged, so as to admit the ringer and per- 
mit the opening of it by a speculum to some extent, so that we may 
see the inside. Now, while this is very generally the case, it certainly 
is not always so. This open condition of the os and cervix is more 



388 PATHOLOGY OF HYSTEEOPATHY. 

frequently met with near the menstrual periods than at any other 
time, and is probably always owing to the congestion of the vascular 
tissue of the cervix and about the os. 

Endocervicitis with Diminished Size. 

I have, undoubtedly, seen many cases of this endocervicitis. in 
which neither the os nor cervical cavity was in the least enlarged, 
and others, in which the os uteri was contracted much below its 
natural size. The secretions of the mucous membrane are always 
modified ; generally they are very much increased, and often changed 
in character. They may become purulent or sanguineous, owing to 
the grade of the inflammation and the degree of congestion. The in- 
flammation situated external to the os, on the end of the uterus, be- 
tween the labia or their external surface, is very common, but it is not 
often limited to this part It is almost always combined with endo- 
cervicitis. 

Special forms of these mucous inflammations are found more. fre- 
quently in certain sorts of patients. 

Endocervicitis in Virgins. 

Virgin patients seldom have inflammation external to the os uteri : 
their disease is endocervicitis almost always ; very rarely there is a 
little rim of inflammation around the os upon the end of the uterus. 

Endocrrvicitis in Aged Women. 

Again, in senile patients, we find the inflammation in the cavity of 
the cervix. The os uteri in the aged is normally small, and simply 
looking at it will seldom convey a correct idea of the state of the cer- 
vical cavity, but the introduction of the probe in cases of endocervi- 
citis will give rise to very great pain. The endocervicitis of old women 
is extremely difficult to manage, and is always protracted. 

External Inflammo.tion combined with Interned in Childbearing 

Women. 

In married, childbearing women we find the external combined 
with the internal uterine inflammation of the mucous membrane. 
They are the kind of patients in whom most frequently the enlarge- 
ments, indurations, and fibro-cellular inflammations are observed. 
The form of disease in persons who have been married, but never 
have been pregnant, partakes to some extent of the character of that 
of the virgin and the childbearing woman. They often have external 
combined with internal mucous inflammation, but not often fibro-cel- 
lular. Now, what I mean by these statements is, that these patients 
are likely to have the forms of disease which I have ascribed to them, 
but there certainly are exceptions to all of them. 



CHAPTEE XIX. 

ETIOLOGY OF UTERINE DISEASE. 

The genital apparatus of woman is in a constant state of predis- 
position to disease. The very turgid condition of these organs for so 
many days in every month is one that in appearance borders so 
closely on the pathological that in other organs it would be taken for 
one of disease, and the symptoms are equally like those caused by 
disease. 

This similarity between menstrual hyperemia and morbid conges- 
tion is so great that it makes it impossible to distinguish the differ- 
ence by sight and touch alone. The color of the menstruating uterus is 
greatly deepened ; the organ is larger, heavier, and less easily moved 
in the pelvis, and we know that it requires only a prolongation of this 
condition to constitute a state of disease. Another degree of nervous 
and vascular excitement would be morbid congestion of the uterus, 
and all experience shows that cold applied to the person when the 
organs are in this condition seldom fails to add that degree of excite- 
ment, or that the same thing may be brought about by standing too 
much or by other unusual exertion. 

The position of the genital organs at the lower part of the body, 
much below the heart, having veins without valves and of weak con- 
tractile powers, is another cause of exceptional hyperemia. 

Add to these the frequent erotic excitement to which they are sub- 
jected in consequence of the peculiar sexual life a woman lives, and 
we have another predisposing condition of great influence. 

By the peculiar sexual life of woman I mean a comparison of her 
life with the sexual life of other animals. 

Female animals do not cohabit night and day the year round, during 
pregnancy and nursing. The interval between the acts of sexual in- 
tercourse in animals is long, and comprises all the time during preg- 
nancy and nursing, while women observe no time of abstinence except 
the few days occupied by the menstrual flow, labor, and the period of 
lying-in. 

Pregnancy and parturition are strongly predisposing conditions. 

The long-continued and very great hyperemia of pregnancy as else- 
where shown causes abrasions and ulceration before labor, while the 
pressure of the uterus upon the bladder, rectum, etc., sometimes gives 
rise to permanent pelvic difficulties. 

Parturition is so generally recognized as a predisposing cause of 
disease that the greatest care is and ought to be taken to conduct pa- 



390 ETIOLOGY OF UTERINE DISEASE. 

tients through it and the post-partum condition in order to avoid 
subsequent difficulties. 

Unusual duration of labor is to be avoided because of the damage 
that may arise from too long pressure by the child's head or pros- 
tration of the nervous system from violent exertion. But in the 
normal labor there are many conditions that predispose to disease. 
The uterus is left large. hypera?mic. and in a state of degeneration, 
with the cervix bruised, lacerated, and denuded of its mucous mem- 
brane. 

The vagina and all of its surrounding tissues have been stretched, 
pressed, and bruised, and the vulva and perineum are torn and bleed- 
ing. "While all these are conditions necessarily attendant upon a 
natural process, and consequently must be regarded as normal, yet 
they are certainly upon the verge of disease, and are predisposing 
conditions prolific of disease. They predispose to acute disease, as 
metritis, perimetritis, cystitis, vaginitis, etc.. but their influence is 
more frequently observable in the chronic affections resulting from an 
incomplete recuperation from the normal accidents of labor. 

But abortion is another strongly predisposing as well as exciting- 
cause to disease of the uterus. In many cases of abortion the organ 
is repaired of damages as well as after natural labor. This, how- 
ever, is an exception to the general rule. Abortion is generally fol- 
lowed by either acute or chronic disease, and sometimes both. The 
reasons for this are too obvious to require any farther consideration. 

Other and very grave predisposing causes may be found under the 
head of puberty and change of life. 

In a state of predisposition from any of the causes above mentioned, 
the application of cold is often productive of congestion and chronic 
inflammation of the uterus and ovaries. 

This is often proved by the results of a cold during the congestion 
just preceding menstruation or at the time of the flow, and in child- 
bed, or for some weeks afterward. 

There are other causes which act in conjunction with the predis- 
posing conditions I have mentioned above, but are sometimes inde- 
pendent in their effects: the abuse of the organs by the practice of 
vicious habits, masturbation, excessive intercourse, etc., standing too 
long, working the sewing-machine, and the pursuit of other employ- 
ments that keep up a stasis of blood in the pelvis. School-teachers, 
sales-women and sewing-girls come within the influence of these 
cau>< s. 

Still other causes are accidents, violence, gonorrhoea, etc. 

Gonorrhoea is a very fruitful source of chronic endocervicitis and 
endometritis. Dr. Emil Xoeggerath* of New York city, believes that 



* First volume Transactions of the American Gvnecological Societv. 



ETIOLOGY OF UTERINE DISEASE. 391 

gonorrhoea is a frequent cause of several forms of inflammation in the 
pelvic organs of women, as of the Fallopian tubes, cellular tissue, 
ovaries, and peritoneum. He finds evidence that it remains in a 
latent condition or form in the mucous membrane, and in consequence 
of the influence of some exciting cause is awakened into an acute 
form of disease, which probably more frequently attacks the pelvic 
peritoneum or cellular tissue. He thinks that gonorrhoea often per- 
sists in this chronic form in the male, and although apparently cured, 
the husband is capable of infecting his wife for years afterward. I 
am quite convinced that his views in this respect are not without 
foundation and deserve the serious consideration of the profession. 
If Dr. Noeggerath's teaching should be demonstrated by further obser- 
vation it will place gonorrhoea as a latent source of mischief on the 
same footing as syphilis. However this may be, I am quite sure that 
chronic endocervicitis, in which the glands of Naboth are the princi- 
pal seat, and when the cervical canal is filled with a tenacious mucus 
of so tough a consistency as to make it difficult to remove, is fre- 
quently of gonorrhceal origin. 

We cannot always trace these chronic cases to an acute attack of 
gonorrhoea, but when we can get at the facts we will generally find 
that the husband has been the subject of gonorrhoea, and probably 
yet has gleet or the chronic form of that disease. 

Under the head of puberty I have pointed out many deleterious 
influences under which the girls of this country are placed, and which 
lead, primarily or secondarily, to the development of sexual disease 
in consequence of natural and social conditions which cannot be 
escaped. 



CHAPTER XX. 

DIAGNOSIS OF UTEKDsE DISEASE. 

Characteristic Signs of Inflammation. 

The signs of inflammation of the submucous tissue or substance of 
the neck of the uterus are. increase of size, tenderness, and generally 
hardness : of the mucous membrane, increased color and secretion ; of 
ulceration, still more intense redness, purulent discharge, tenderness, 
and not much enlargement. The former conditions may be ascer- 
tained by the touch, the latter by the sight, and when they are 
mingled, by both combined. Open external abrasion or ulceration 
of the uterine cervix, after the parts are well exposed, and cleared of 
mucus and. pus by wiping, cannot be well mistaken or overlooked ; and 
the practitioner must not be led to believe the case one of no impor- 
tance because the ulceration is not very extensive. This raw scarlet 
surface is always indicative of mischief, and we should expect any 
amount of suffering from even a small patch of it. 

Diagnosis of Endocervicitis. 

There are cases where the appearances are not so obvious, where, 
in fact, all the parts exposed by the speculum and within reach of 
our vision have a natural appearance. Xo redness, rawness, or other 
discoloration can be detected on the neck, in the mouth of the uterus, 
nor on the vaginal surfaces : they are quite healthy in appearance 
and reality. Van there is an obvious and. in many instances, a copious 
secretion of tenacious mucus flowing from and lying in the os uteri ; 
wipe this away and all looks right. This is a case of endocervicitis. 
In some instances this mucus is colored with streaks of yellow by the 
presence of pus. or it is wholly yellow ; here there is loss of integrity 
in the epithelium of the cervical cavity. The mucous membrane in 
the cervical cavity is ulcerated. If we remember that the mucous 
membrane secretes only enough mucus for lubricating purposes in 
the natural condition, we can arrive at no other conclusion than that 
the membrane is in a state of hyperexcitement when its secretion is 
abundant or altered, or both. When we see mucus in even small, yet 
perceptible quantities, issuing from the anus, what is the inference ? If 
this is abundant, persistent, and colored yellow, however healthy the 
anus might appear externally, we could not believe that the rectum 
was in a healthy condition. Why not then positively determine that 
he mucous membrane is inflamed, which floods the os uteri with 



DIAGNOSIS OF UTERINE INFLAMMATION. 393 

mucus or pus, or with both? If we introduce the probe into the 
cavity of the cervix thus abundantly secreting, the patient will nearly 
always complain that we touch a "sore place, a tender spot," that it 
hurts her in her back, etc. And very often blood will immediately 
follow the withdrawal of the instrument. This, however, is not inva- 
riably the case. Another diagnostic evidence of endocervicitis is the 
increase of the pain ordinarily experienced by the patient when the 
probe or application is introduced. 

The hypersecretion, or perverted secretion of the mucous mem- 
brane, must then be regarded as an indication of disease of that mem- 
brane. If we have these facts fixed in our mind, and if we act upon 
them, we may discover and cure disease that would otherwise escape 
our attention and thwart our skill. But there is another obvious and 
common-sense sign of inflammation which has not been applied in 
our investigations of diseases of the uterus, viz., tenderness. Tender- 
ness or sensitiveness to the touch anywhere else leads us to suspect 
inflammation, but in the uterus it is unaccountably set down as indi- 
cating an irritable uterus and not an inflamed one. 

Diagnosis of Submucous Inflammation. 

I think when I touch the uterus with the finger or an instrument, 
and the patient shrinks from the contact and says " she is sore," or 
" it is sore," that there is inflammation there. Tenderness is not an 
evidence of mucous inflammation, but of submucous or fibrous in- 
flammation of the uterus. 

Complication of Mucous with Submucous Inflammation. 

The uterus should be examined by the same diagnostic rules that 
govern our investigations of disease in other organs. Some authors 
tell us that ulceration results from inflammation of the submucous 
tissue, and others that the inflammation begins in the mucous mem- 
brane. However this may be, I am sure that inflammation some- 
times exists in both these tissues at the same time. In this case we 
shall have tenderness and hypersecretion. At other times there is 
submucous without mucous inflammation; then we shall have ten- 
derness without hypersecretion. Again, we may have mucous with- 
out submucous inflammation, when hypersecretion without tenderness 
will indicate it. These remarks will fix the importance of these two 
symptoms as indicating the seat of the disease. 

Size of the Uterus ordinarily Increased — Exceptions. 

The size of the organ is one indication of the presence or absence 
of inflammation ; but this may vary very much under what would 
appear to be the same form of disease. In endocervicitis it is usual 



394 DIAGNOSIS OF UTERINE DISEASE. 

to find the cervical canal increased in calibre ; but this is certainly 
not always the case, as I have met with unmistakable instances in 
which this cavity was decreased in size and the os uteri almost closed, 
it being so small as to admit only a very small probe. Where there 
is mucous inflammation of the cervix extending toward the cavity of 
the body, and more particularly where the disease extends into the 
cavity of the body, the whole organ is likely to be enlarged. So much 
enlargement sometimes takes place that the fundus may be felt con- 
siderably above the pubis. Neither is this always the case, however ; 
often there is no enlargement. The hypertrophy, or general enlarge- 
ment of the organ, is more frequently indicative of mucous than sub- 
mucous or fibrous inflammation. 

Atrophy as the Result of Inflammation. 

In fact, I think that long-continued inflammation of the substance 
of the body and cervix often brings about atrophy or shrinking of the 
uterus. Permanent increase of size or hardness of the cervix must be 
the result of submucous inflammation, and generally coexists with it. 

Almost the only disease with which chronic inflammation and ulcer- 
ation of the cervix uteri are likely to be confounded, is cancer in some 
of its stages. The many well-marked symptoms and physical condi- 
tions which accompany this last disease are now, however, so well 
understood and so thoroughly described, that the novice need not be 
embarrassed in his diagnosis of it. 

I find in Becquerel's Traite Clinique des Maladies de Uterus, pp. 320- 
323, vol. i., so complete and faithful a diagnostic summary between 
cancer and the different conditions of chronic inflammation of the 
cervix, that I have translated and given its substance for the conclud- 
ing portion of this chapter. It is subjoined : 

Cancer in the Scirrhous Condition. Inflammation and Ulceration. 

Cervix hard, unequal, nodulated ; os not Neck less hard, developed regularly in 

always open, sometimes wrinkled or one of the lips; os always open, 
furrowed. 

Scirrhus of the neck often implicates the The induration of the neck never ex- 
vagina, tends to the vagina. Mobility of uterus 

complete. 

Hereditary influence is often traceable. No hereditary influence. 

Touch is painless. Touch painful. 

Discharge sometimes absent; in certain Discharge constant, and characterized by 

cases very abundant, and consisting, for the presence of transparent mucus, 

the most part, of albuminous serum. muco-pus, or purulent mucus. 

Menstruation increased, being neither Menstruation more painful, often re- 
more nor less painful, and passing tarded, almost always scanty, 
often into the state of real hemorrhage. 

Absence of special anaemia when the Special anaemia, as above described, 
vagina and body of the uterus are in- 
volved. Cancerous cachexia. 



ATEOPHY AS THE RESULT OF INFLAMMATION. 



395 



Cancer in the Scirrhous Condition. 

Progress continuous and without cessa- 
tion. **> 

The pain in cancer is very sharp, intense, 
and lancinating, and not influenced by 
locomotion or movements of any kind. 



Inflammation and Ulceration. 
Often stationary for a long time. 

Pains less severe, more dull, and percep- 
tibly influenced by walking and other 
sorts of motion. 



Ulcerated State. 

Developed at the critical period of life 
generally. 

Preceded and accompanied by hemor- 
rhages. 

Severe, sharp, lancinating pain. 

Development essentially in sharp irregu- 
larities and nodosities. 

Adhesions to other organs as soon as ul- 
ceration is formed ; immobility of the 
uterus. 

The surface only slightly soft ; subjacent 
tissue scirrhous. 

Ulceration deep, unequal, essentially ir- 
regular, with thick, elevated, and hard 
edges. 

Always granulations. 

Discharges extremely abundant, consist- 
ing of purulent and often sanguineous 
serum ; nauseous and often fetid odor. 

Great hemorrhage from time to time, not 
necessarily at menstrual period. 



Chronic Inflammation and Softening. 
Occurs earlier in life almost always. 

Not preceded by hemorrhage. 

Pain dull and profound. 

Enlargement regular and rounded, or 

regularly lobulated. 
Complete absence of adhesions to other 

organs. Entire mobility of the neck 

and body of the uterus. 
Tissue of the cervix not hard, and easily 

destroyed. 
When ulcerations exist, less deep, with 

tumefied edges. 

Granulation often accompanies the other 
lesions. 

Discharges less abundant, consisting of 
muco-pus alone, or accompanied with 
a little blood, without odor. 

Always hemorrhage, but often a mere pro- 
longation of the menstrual discharge. 



Cancerous Ulceration. 

Developed upon a hypertrophied and 
scirrhous surface. 

Ulceration deep, vast, unequal, grayish 
surface, with thick edges, and easily 
bleeding. 

Ulcerated surface hard, presenting numer- 
ous lobes and tubercles, with nodosities 
and great hardness. 

Often great loss of substance. 

Cervix and corpus uteri immovable, on 
account of adhesions. 

Discharges sanious, fetid, sanguinolent, 
and of an insupportable and character- 
istic odor. 

Cancerous cachexia always present. 



Simple Ulceration. 

Ulceration often on a healthy tissue, or 
presenting the soft or hard varieties or 
inflammatory injection. 

Ulceration more superficial, the edges 
less developed, and more regular at 
the bottom, not always easily made to 
bleed. 

Nothing of the sort in chronic inflamma- 
tion and ulceration. 

Ulceration is not always accompanied with 

loss of substance. 
Neck and body always movable. 

Discharge of muco-pus, or purulent mucus, 
always more or less abundant. 

Special anaemia. 



396 DIAGNOSIS OF UTERDTE DISEASE. 

M Professor Otto Spiegelberg, speaking of the difficulty of distinguishing between 
simple inflammatory induration of the cervix uteri — hyperplasia — and carcinomatous 
infiltration, gives the following as a certain indication of cancerous infiltration, viz. : 
* A peculiar induration of the cervix, the disposition of its mucous membrane, and its reaction 
to the dilatation of sponge tents. 1 He expounds each member of this rule. 

"The hardness of cancerous deposit, in comparison with simple induration, is well 
known ; but the distinction is frequently impossible to make out. even by the most 
cultivated touch. The two other symptoms are unequivocal, and are as follows : 

" ' First, the mucous membrane in cancerous growth is firmly connected with the un- 
derlying induration, and immovable over it, which is not the ense in mere hyper- 
plastic thickening and induration ; and, second, while the latter, under the pressure 
of compressed sponge, in the cervical canal, becomes regularly even, though at times 
inconsiderably looser, softer, and thinner, the cancerous infiltration remains unalter- 
ably hard and rigid, and cannot be stretched.' He goes on to explain the reason for 
this difference between the products of the two inflammations from the locality where 
the cancerous inflammation originates, which is the utero-malpighii ; or, in extremelv 
rare cases, from the glands of the cervical canal. The latter form gives rise to the al- 
veolar or colloid form, of which he has only seen one case. As a rule, the disease is 
developed from the interpapillary depressions of the epithelium. According as the 
growth of the epithelium into the tissues below is or is not attended by a simultaneous 
growth of the papilla?, two forms of cancer may be distinguished, — the papillary, 
villous, or cauliflower excrescence, and the simple infiltrated form." — Cincinnati 
Clinic {from Archil fur Gynakologie). 



CHAPTER XXL 

GENERAL TREATMENT OF UTERINE DISEASE. 

Main Objects of General Treatment. 

The main object to be gained by general treatment is to palliate the 
general condition of the system, to aid the local in effecting the cure, 
and to remove, when practicable, the effects left after a cure of the 
local disease. A cure of local chronic disease, by general treatment 
alone, is hardly to be expected, although, in some instances, it may 
be indispensable to such a result. When general treatment is used as 
a palliative or adjunct in local diseases, it is directed to the relief of 
general symptoms attendant upon them. It will be impossible for 
me to notice the treatment necessary in all the symptoms which attend 
and add to the distress of our patients in uterine diseases, but there 
are certain prominent and troublesome ones on which I cannot with 
propriety omit to dwell. I do so the more readily from the embarrass- 
ment which I know, from experience, fills the mind of the inexperi- 
enced as to the proper value to place upon general treatment and the 
course to be pursued. 

Many of the patients laboring under chronic uterine disease come 
to us broken down, the subject of a multitude of symptoms resulting 
from inanition and depraved functions. These prostrated patients, 
it will be found, have passed through the primary sympathetic suffer- 
ing I have elsewhere described, and are in the midst of that condition 
we have been in the habit of calling nervous prostration, in which 
general treatment becomes a very important, if not an essential, means 
of success. This general treatment consists in the correction of the 
condition of the organs which were first sympathetically deranged, — 
the stomach and its associate organs, — introducing into the system 
nutritive material enough to relieve the anaemic state of the nervous 
centres, and conducting the patient back to her long-lost habits of 
activity. I have elsewhere expressed the opinion that the primary 
morbid condition of these organs is functional derangement, and, 
perhaps, always deficiency of their secretions. One of the first and 
most important things to be done is to correct this derangement, and 
the two medicines that have occurred to me to be the most efficient 
are mercury and nitro-muriatic acid. Mercury has always, and very 
deservedly, had the reputation of exciting the glands connected with 
the alimentary canal, viz., the salivary, gastric, duodenal, — liver and 
pancreas, — and those of the large intestine. Administered in small 



398 GENERAL TREATMENT OF UTERINE DISEASE. 

doses, this excitement does not transcend the limits compatible with 
health ; but given in larger doses, it produces inflammatory excite- 
ment in all of them. We can very properly avail ourselves of this 
quality of mercury in such a manner as to increase the action of all 
these glands, and thus promote the appetite, and digestion and assimi- 
lation. It is, in this way, an efficient tonic, increasing the red blood- 
corpuscles and establishing a plastic habit so desirable in chronic 
diseases. To these broken-down patients I am in the habit of admin- 
istering it in the form of blue mass or the bichloride ; of the former, 
one-third of a grain four times a day, or one grain at bedtime. When 
I give the bichloride, I generally dissolve it in the compound tincture 
of cinchona, one-sixteenth of a grain of the mercury in a tablespoonful 
of the tincture three times a day, after meals. These doses are too 
small for some patients and too large for others. When not large 
enough, they are not attended with any appreciable results, in which 
case a slight increase will be necessary. When the dose is too large 
it generally causes diarrhoea. When it produces this last effect, it 
should be withdrawn and the acid substituted, which should be given 
in very small doses. 

Dr. L. F. Warner, of Boston, wrote an article in advocacy of the use 
of mercury in the treatment of uterine disease for the obstetrical sec- 
tion of the American Medical Association. It was published in the 
Transactions of 1878. Dr. Warner brings forward cases to show the 
efficacy of this drug, and the article will repay perusal. 

It should be remembered, however, that medicines are but prompt- 
ers to nutrition, and that to reinstate the lost vigor the patient must 
be fed. Her anorexia should be no excuse for starvation ; food should 
be taken in sufficient quantities to nourish her, with as much persist- 
ence and regularity as she takes her medicine. If we wait for an 
appetite, starvation will go on ; and if w T e wait until digestion is com- 
fortable, we may often wait until inanition establishes tuberculosis, 
leucocythsemia or some other equally fatal disease. 

We ought to prescribe and particularize what, in our judgment, is 
necessary, and insist upon its being taken. About the only reason for 
withholding any article of diet indicated is the rejection of it. Diges- 
tion is likely to be attended with discomfort of some kind, such as 
fulness, cardialgia, pyrosis, etc. ; but as the blood becomes better, by 
virtue of its tonic influence upon the organs, the secretions in the 
stomach will improve, its muscular coats become stronger, bile and 
pancreatic secretions become normal in quantity and quality, and the 
digestion will be complete, easy and comfortable, and the patient 
will regain her strength. 

The articles of diet which can be tolerated will not always be the 
same. When I say tolerated I do not mean desired and digested with 
comfort, but I mean such as will not be rejected from the stomach, for 



NERVOUS PROSTRATION. 399 

if they are not vomited up, and do not cause diarrhoea, they will be 
digested, and hence be the source of nutrition. 

As concentrated food, and generally the most nourishing, are the 
different kinds of animal food ; beefsteak, roast beef, mutton chops, 
roast or boiled mutton, milk and eggs, butter, etc., constitute a good 
assortment from which to choose and prescribe. 

In prescribing meat in any form we will generally be met with the 
objection: "I do not eat meat; I do not care for meat; I have no 
appetite for it." I sometimes think, as medical men, we ought to 
reject the word appetite from our vocabulary. These patients usually 
have no appetite, and for that very reason are starved. If we do not 
prescribe the very articles we want them to take, the exact quantity 
and the time for taking them, they will generally disregard our direc- 
tions.. We may tell them to take two ounces of beefsteak or mutton 
chop for breakfast, the same quantity for supper, four ounces for din- 
ner, with bread and butter, vegetables, and every such other thing as 
they wish, but always the meat. Then if we prescribe one pint of 
milk after each meal, and one at bedtime, the patient will have a good 
strong diet, and it will soon be apparent in her improved condition. 
The nurse should be responsible for the taking of this prescription, as 
she is for the administration of medicines. 

Some patients cannot chew their meat, but can swallow and digest 
it if it is minced finely. It will digest in this form usually very per- 
fectly. 

General Symptoms requiring Special Attention. 

The symptoms, the treatment of which I propose to speak of in 
detail, are : 1st. General nervous prostration ; 2d. Nervous excitability, 
exaltation of nervous excitement; 3d. Anaemia; 4th. General plethora; 
5th. Local plethora ; 6th. Constipation ; 7th. Indigestion. These are 
generally more or less complicated with each other, and sometimes 
several of them coexist; but, ordinarily, some one assumes the most 
prominence, and occasions most distress, and consequently requires 
more of our attention than the others. 

Nervous Prostration. 

There is often great nervous prostration, and a sense of weakness, 
when, so far as we can judge, haematosis and nutrition are usually 
well performed. The cause of this depression must be sought out 
in each case, as there is no uniformity in the functional deviations. 
Very frequently there is a deficiency of menstrual discharge, the 
scantiness being very obvious ; at other times it is too copious. We 
should inquire into the functions of all the important organs, and 
correct them, when disordered, as nearly as possible, by changing the 
habits and circumstances of the patient, and afterward, or in connec- 



400 GENERAL TREATMENT OF UTERINE DISEASE. 

tion, address remedies to the organs themselves. The stomach, liver, 
bowels, skin, kidneys, and uterus should furnish their discharges in 
the most natural manner, and if they are not doing so, should be 
corrected by the most gentle means. If several of these organs are 
in a state of functional deviation from health, we should not expect 
to correct them all at one time, but alternate our attention between 
them ; first, with our remedies influencing one, and then another. I 
insist here, with reference to the plan to be pursued, that we should 
not address all these organs, or even a large part of them, with me- 
dicinal agents at one time. There is no question, I think, that com- 
plicated formulae often nullify themselves by containing ingredients 
intended for the liver, kidneys, and skin, which ought all to act about 
the same time. We should act upon each of these alternately, in 
quick succession, if we think best ; but let each organ feel the full 
impression of its remedy before the blood and nervous energies are 
directed to another. In addition to this indirect way of increasing 
the tone of the nervous system, it is natural for us to look about for 
something that will act more directly. Our patient becomes so de- 
pressed, and suffers so much from terrible feelings of prostration, that 
her condition appeals to our sympathies for a more direct and imme- 
diate relief. If left to themselves, or the advice of injudicious friends, 
they almost always resort to stimulants, as whiskey, ether, chloro- 
form, ammonia, etc. In some cases only are these temporary reme- 
dies advisable, and when used, they nearly always leave the patient 
in a worse condition than before they were taken. They are allow- 
able only as necessary evils, and should be avoided when possible. 
These patients are usually depressed mentally, also, and much good 
may be done by operating upon their minds. A physician who enters 
the room with a cheerful countenance, and a pleasant and gentle 
bearing toward the patient, and who engages her in conversation, 
first about her case, and afterward about some favorite theme, will 
do more toward temporarily relieving the great nervous and mental 
depression than all the ether and ammonia the stomach can be made 
to bear. Earnest and kind assurances that her symptoms, though 
causing her a great deal of suffering, are not of a serious nature, and 
will soon subside, act generally as a good cordial to the spirit and 
nerves. In paroxysms of excessive nervous prostration, despondency, 
etc., I have seen the tonic influence of very cold air do a great deal 
toward relieving them. These paroxysms generally occur in close 
and overheated rooms, two conditions which should be removed. If 
it is cold weather, we should cover the patient to protect her, and let 
the frosty air— the colder the better— into the room, by opening all 
the windows and doors, and keep the room cleared of visitors. It 
will astonish anybody who has not observed the effect of a tem- 
perature near to zero on those swooning hypochondriacs. A change 



NERVOUS EXCITABILITY. 401 

almost immediately occurs for the better. If the air is not cold, it 
will still do much good to give it perfectly fresh to the patients in 
abundance. When able, they may be taken outdoors. This treat- 
ment introduces the natural stimulants, oxygen and cold, into the 
lungs, and brings them in contact with the nerves, and is more en- 
livening than medicine. How long the room should be kept open 
and cold will depend upon the effect, but we should always, if pos- 
sible, make these patients sleep in open, cold rooms. This is a very 
important item, which it will often require ingenuity as well as 
authority to enforce. These patients should live outdoors as nearly 
as possible, and be as much as they can on their feet. 

Food, etc. 

Their food should have reference to the condition of the abdom- 
inal functions entirely, and be regulated by them. There is gener- 
ally great intestinal torpor, which should be removed if possible.* 
Good, cheerful company, travel, — if the patient will not employ her 
body and mind in domestic pursuits, — temperate and reasonable di- 
versions, and, above all, time and patience, are requisite remedies. 
The affection is obstinate and chronic, and with the most judicious 
management will require time, if it does not vanish as the local treat- 
ment advances. 

Nervous Excitability. 

Connected with it often in some manner is great nervousness, exci- 
tability, irritability, or exaltation of all the nervous phenomena. This 
nervous irritability shows itself in great mental excitability, want of 
sleep, unreasonable agitation, restlessness, dissatisfaction ; in short, in 
almost every phase of mental, muscular, or nervous excitement. 
There is also excitability of the different organs, with or without 
general nervousness, palpitation of the heart, nervous headache, local 
muscular contraction, etc. Successful management of these nervous 
and excitable patients requires a careful scrutiny into their general 
condition ; the chylopoetic functions should be regulated in the most 
careful manner, the skin and kidneys should be attended to with great 
watchfulness. All that I have said as to general management in cases 
of nervous depression will apply to this kind of cases. As complete 
a revolution of the circumstances of the patient should be made as is 
practicable. From a life of ease, luxury, and absence of care, she 
should be, if possible, placed in circumstances requiring care, with 
muscular outdoor exercise to the greatest extent she is capable of. If 
we cannot place our patients in situations which their cases require, 
we can send them on journeys that will demand exertion, calculation, 

* See remarks on treatment of Constipation. 
26 



-J 02 GENERAL TREATMENT OF UTERINE DISEASE. 

care, and the deprivation of their usual domestic luxuries. The re- 
mark is frequently made that we must temper our remedies to the 
delicacy of the patients: and I am afraid that this injunction is mis- 
construed into the necessity of too great tenderness of treatment. The 
better rule is to make use of such means as will raise the patient from 
her state of delicacy to robustness. It is the delicacy of her constitu- 
tion that causes her to sutler so much. This can be strengthened only 
by proper physical, moral, and mental training. The moral and 
mental condition of our patients when so very excitable should be 
attended to. Improper reading and society should be avoided; and 
social and literary habits should be reduced to great plainness and 
simplicity. Above all things, books and society should not interfere 
with regular rest, exercise, and outdoor exposure. As I have said 
before, this last should be as great in amount as can be borne, aeeom- 
panied with active muscular exercise, as walking, and should be prac- 
ticed in all weathers, sufficient protection being secured by enough 
clothing of the right sort. With regard to the use of medicine, is is a 
fact, that it is an exceedingly difficult thing to find any remedy that 
does not produce exaggerated and in most cases disagreeable and even 
injurious effects. So much excitability of the nervous system nearly 
always modifies the effects of remedies, and we can seldom predict 
the operation of any of them, nor can we determine the value of any 
until they have been tried. When tonics can be borne, they often 
very much relieve and sometimes entirely cure this great nervous ex- 
citability. Of the mineral tonics, probably bismuth, arsenic, and zinc, 
agree best. Iron is frequently not tolerated in any shape by these 
very nervous patients. Quinine, mix vomica, cherry, and chamomile 
are the best vegetable tonics, but we must not be surprised if none of 
them are borne. Alcoholic stimulants, in general, agree with them, 
and are the best cordials for temporary nervous excitement, but should 
be conscientiously avoided when possible, as not a few, I am sorry to 
say. of most estimable and intelligent women have used them too 
much, and engendered an appetite that could not be denied. Opium. 
and, in fact, the narcotics generally, fail to have any good effect, but 
on the contrary disagree with the patient. This, however, is not 
always the case with opium, as it acts like a charm with some. In 
all it should be studiously avoided as deleterious in the long run. 
and there is danger of creating an appetite for it. We may the more 
readily be persuaded to omit the use of all these medicines, as their 
effects are temporary, while remedies hygienic and regiminal are per- 
manent in their effects. The management of those cases of localized 
nervousness or unnatural excitability in particular organs, as palpita- 
tions of the heart, nervous headache, etc.. is about the same as above, 
except that more attention to the stomach, from which they usually 
arise, may be necessary. 



ANEMIA. 403 

Some forms of nervous excitement are very much benefited by the 
bromide of potassium. Severe nervous headache, watchfulness and 
neuralgic pains are often greatly relieved by this remedy. It should 
be given in full doses. For headache, from thirty to sixty grains 
every hour until relief is obtained. For wakefulness, the same quan- 
tity an hour before and at bedtime will sometimes procure a good 
night's rest. When given in full doses it should be dissolved in a 
large quantity of water, to prevent it from irritating the mucous 
membrane of the alimentary canal. I have sometimes succeeded in 
averting the return of the syncopal convulsions described under the 
head of general symptoms. One patient now under my care had 
been the subject of them for twelve months, having them several 
times a month. They had become so frequent and violent as to 
induce the fear of epilepsy, and had been treated with many remedies 
without material benefit. She has been taking the bromide of potas- 
sium for six months in doses of thirty grains three times a day, and 
during that time has had no convulsions. She is under treatment for 
endocervicitis. It remains to be seen, of course, whether this im- 
provement be permanent, nor can I say how much of the ameliora- 
tion may depend upon the treatment directed especially to the uterus. 
It is certain, however, that the " paroxysms," as she calls them, were 
improved immediately upon the commencement of the bromide treat- 
ment, and before I could reasonably expect benefit from the rest of the 
remedies. 

We undoubtedly have a valuable means of relief from the pains 
attendant upon the condition of many of these patients in the hy- 
drate of chloral, while it is often as prompt and positive in the relief 
it affords in sleeplessness and pain. So far as I am aware, it is not 
followed by the very disagreeable effects that result from the adminis- 
tration of opium and its preparations. It, too, should be dissolved 
in an abundance of water, to prevent it from producing local irrita- 
tion upon the mucous membrane of the stomach, as it often otherwise 
causes vomiting or decided nausea. 

Anaemia. 

Angemia, with its disagreeable concomitants, sometimes also calls 
for separate treatment. It would be an unnecessary waste of time and 
space to enter minutely into the general treatment necessary, where 
anaemia is the prominent and troublesome symptom. This condition 
calls for the same treatment found useful under other circumstances, 
and, while it may not be entirely amenable to it, it will be very much 
benefited by the remedies indicated by the state of the blood. Iron, 
cod-liver oil, quinine, bitter infusions, and- nutritious diet, with out- 
door exercise to the extent the patient can bear, are the efficient 
remedies. 



404 GENERAL TREATMENT OF UTERINE DISEASE. 

Plethora. 

But we sometimes find general plethora instead of anaemia, a state 
in which there is actually an unusual amount and too rich a com- 
position of the blood. I need not dwell upon this general state of 
the system, as the treatment is simple and familiar. The great fear 
is that, on account of the painfulness about the hips and legs, the 
patient may be too much inclined to an inactive life. On no account 
should this class of patients be allowed their ease; they must be 
urged to use up their surplus blood in active exercise, and the kind 
of exercise, next to the cares and labor of a household, best adapted 
to them, is walking. Every muscle in their body must be brought 
into action ; every secretion must be kept free, and the mind ought 
to be taxed to continuous effort during the day by some useful occu- 
pation, while the strictest temperance, with reference to ingesta, 
should be their rule of living. Obesity, and the troublesome and 
dangerous effects of plethora, connected or unconnected with general 
plethora, will be thus avoided. 

Local Congestions. 

"We sometimes meet with instances of violent, dangerous, and even 
fatal determinations of blood to particular organs, as the consequence 
of the general ill-health which accompanies uterine disease, such as 
stupor, stertorous breathing, etc., indicating an oppressed condition of 
the brain, great dyspnoea, and sense of suffocation, showing congestion 
of the lungs. The treatment of these congestions does not differ from 
what would be appropriate under other circumstances of their occur- 
rence, and consists in revellents, alteratives, etc. The most frequent, 
and perhaps obstinate, of the local congestions are such as occur in the 
chylopoetic viscera, manifested by excessive secretion and discharges 
from the stomach and bowels. It is not uncommon for these patients 
to have suddenly recurring attacks of vomiting, cramps in the stomach 
and bowels, diarrhoea, and consequent great distress. Aside from the 
local treatment, we shall be called upon to exert our skill against the 
exhausting and depressing influences of these attacks. It will almost 
always be found that such attacks are preceded by constipation, with 
scanty secretions, furred tongue, and other evidence of unhealthy 
secretions. By carefully correcting this condition we may avert these 
painful and exhausting occurrences. The plan recommended and so 
much prescribed by Abernethy will often palliate very much, viz., 
six or eight grains of blue mass, at night, worked off by some saline 
cathartic in the morning of every fourth or fifth day. If there is 
more permanent diarrhoea, great care should be exercised in the choice 
of diet ; the use of warm baths should be recommended, very warm 
clothing, and not much medicine, as the cure will depend upon the 



CONSTIPATION. 405 

appropriate treatment of the local disease, instead of the treatment of 
the general symptoms. All these symptoms, except the diarrhoea, are 
apt to be moderate, and can be borne until the diseased uterus is cured ; 
but there are two symptoms so very annoying, and which require so 
much patience in the treatment, and exercise so much unfavorable 
influence upon the uterine disease, that I hope I shall be pardoned by 
the reader for dwelling upon them more at length. 

Constipation. 

I allude to constipation and indigestion, particularly the former. 
I have already spoken of the deleterious influence of constipation, 
and I think I am justified in saying that, if disregarded, it retards 
the cure of chronic diseases of the unimpregnated uterus more than 
any other sympathetic affection. And I wish to warn the practitioner 
to be very particular in attending to this symptom. There is proba- 
bly more tendency to costiveness in females than in males, chiefly 
owing to difference in habits. Sedentary life, confinement to close, 
badly ventilated rooms are among the circumstances that bring on 
this condition. Irregularity of meals, late hours, deficient sleep, con- 
centrated diet, imperfect mastication of food, all should be corrected, 
as any one of them alone will do harm, and all or any of these com- 
bined — and this is frequently the case — are very deleterious to the 
functions of the alimentary canal. But an inexcusable and very com- 
mon custom of most females is making the act of defecation a disa- 
greeable and procrastinated necessity, instead of a pleasant and punc- 
tual duty. The most trivial excuse — the presence of friends; a little 
cold, hot, or wet weather; being among strangers; or a slightly in- 
convenient distance from a proper place — will frequently be sufficient, 
to limit defecation to once a week; then the act is performed in a 
hurried manner. It is amazing to know to what lengths this negli- 
gence is often carried. I have known two weeks to have transpired, 
frequently, according to the history of patients, without any attempt 
to relieve the bowels. Now this should be corrected by persistent 
method. The habit of eating from hunger at certain hours depends 
upon lifelong practice, and, when once established, cannot be changed 
without violence to many functions, causing urgent and repeated de- 
mands upon the system for a resumption of it. Regular bowels come 
from an equally long-continued habit of going to the close-stool at 
particular hours of the day. Years of negligence destroy the habitual 
regularity with which the bowels move ; hence we should not be dis- 
couraged if the habit be not re-established without long perseverance. 
A new habit cannot be formed, nor an old one altered, without long 
and persevering effort in the right direction. We should, therefore, 
encourage a patient that is in earnest in her search after health, to 



4C6 GENERAL TREATMENT OF UTERINE DISEASE. 

persevere for months, years, and indeed her whole life if necessary, 
in going to her water-closet without fail, once every day. at a certain 
hour, as regularly as the clock points to it, This is indispensable to 
a correction of the bad habit of constipation. A very effective part 
of this regular endeavor is to cause the mind to dwell upon the neces- 
sity for an evacuation, and the process itself, for at least half an hour 
before retiring to the proper place. It is not a difficult matter, vith 
many persons, to create a desire in this way. Let no consideration 
of convenience enter into this punctual effort at stool. Arrived at 
the proper place, the position should be an easy one ; no inconvenient 
strain upon any muscle should be allowed, and the patient should be 
possessed with an entire sense of leisure to perform the act completely. 
The value of all these considerations, where faithfully followed, is 
incalculable, and very few cases can long resist them. Without them, 
medicine will only temporarily relieve, instead of permanently curing 
obstinate cases. I should caution against severe effort, or straining, 
as it is called; let time, patience, and gentle effort be the plan. 
Another matter of great importance, when an effort is made to have 
an evacuation, is to have the abdomen distended by ingesta. The 
patient should be instructed to eat plentifully of vegetable diet, such 
as by its bulk is calculated to produce fulness. If the patient go to 
the water-closet with a sense of fulness in the abdomen, success will 
be much more likely. Should the regular time for making an effort 
be soon after breakfast, which is undoubtedly the best time, and the 
meal has not been sufficient to produce a sense of moderate distension, 
a full glass of water will complete that condition. For the purpose 
of giving fulness and a sense of distension, various kinds of ripe fruit 
may be resorted to with advantage. In prescribing fruit for consti- 
pation, we should bear in mind that there are three indications ful- 
filled by it, some kinds fulfilling all, while others fulfil only a part 
of them. They are, first and best, distension; secondly, increase of 
secretion, on account of the acids; and, thirdly, increasing peristaltic 
action of the bowels by indigestible fibres, seeds, or rind. Ripe and 
mellow apples, without being divested of the rind, may be eaten in 
sufficient quantities to produce a sense of fulness, and this should 
always be at the conclusion of a meal, — breakfast, for instance; the 
acids will increase the intestinal secretion, and the rind quicken the 
peristaltic motion of the bowels by acting directly upon the mucous 
membrane, and through it on the muscular structure. Very acid 
fruits, as the lemon and orange, only produce their effect on account 
of the acids they contain. They are excellent as a part of the ingesta 
of patients whose stools are dry and hard and lumpy. Fruits con- 
taining an abundance of seeds, as figs, or of rind, as tamarind, etc.. 
increase the peristaltic action without causing much secretion. By 
inquiring into the character of the stools, we shall have a good guide 



CONSTIPATION. 407 

as to the kind or mixture of fruits to be selected. There are kinds 
of diet, breads particularly, that act like these last fruits, and may be 
used in conjunction with or independent of them. Breads in which 
the bran, or hull of the grain, is contained in considerable quantities 
are of this character. The Graham bread, as it is usually called, 
ordinary coarse, brown, corn bread, or wheat bread, are those mostly 
resorted to. When this kind of bread is used for constipation, it 
should be eaten at breakfast, dinner, and supper, in such quantities 
as the experience of the patient finds necessary. I have advised 
patients who could not use the coarse breads to make what may be 
called bran crackers. A tablespoonful of flour, one pint of wheat 
bran, two tablespoonfuls of white sugar, and water enough to make 
them all into a pasty mixture, are the ingredients. This mixture is 
made into cakes, small or large, as may be wished, and baked in an 
oven until hard. When soaked in tea, coffee, or milk, they are not 
unpleasant. I have known patients benefited by swallowing certain 
seeds, with the rind, whole. A tablespoonful of wheat grains, oats, 
barley, white mustard seed, etc., can all be used for this purpose, and 
are not more disagreeable than medicines. Another kind of diet, 
which may be used to produce the kind of effect here aimed at, con- 
sists of the various small vegetables, as celery, radishes, pepper-grass, 
lettuce, asparagus, cabbage, etc. These may all be taken in quantities 
to cause distension. 

In speaking of fruits, I ought to mention the berries as excellent, 
cheap, and easily procured, to accomplish all the objects attained by 
other fruits. 

Everything should be done by habitual effort, exercise, diet, drink, 
etc., before resorting to the use of medicines ; because, as is well 
known to the patients generally, as well as to the practitioner, the 
more medicines taken the more will be necessary. They lose their 
influence, and the dose must be increased in order to produce a full 
effect. Notwithstanding this evil, we are often reduced to the necessity 
of using laxatives to overcome constipation. To a just and intelligent 
application of medicines in the treatment of constipation, it is indis- 
pensably necessary to make ourselves acquainted with the condition 
of the alimentary canal, with reference to its secretions and muscular 
powers. It will be found that there are sometimes great deficiency of 
secretion, and torpor or want of vitality of the muscular structure, or 
weakness of this tissue. The want of secretion may be in the upper 
portion, in which case the bilious color is wanting in the stools, or the 
small intestines may give out less watery material, and then the stools 
are less fluid, or even dry. The secretions may also be deficient in the 
lower portion, or colon ; in which case the faeces will be scybalous, dry, 
and lumpy. The muscular torpor, from want of irritability, is more 
frequent in the colon or rectum than in the small intestines. When 



408 GENERAL TREATMENT OF UTERINE DISEASE. 

in the colon, there is increase in size of the lower abdomen, sense of 
fulness and hardness, and the fseces are expelled with great difficulty. 
If there is sufficient activity of the colon, but the rectum is torpid, 
large accumulations occur there, the pelvic distress is increased, and 
nervousness, general and local, is exceedingly annoying. Sometimes 
all these conditions are combined to render the case one of the most 
troublesome and difficult to manage. Mechanical obstruction by 
stricture of the rectum, formed by pressure of the uterus, may give 
rise to chronic constipation, which may become permanent and almost 
incurable ; or the uterus, by lying on the bowel, and pressing it against 
the sacrum, often gives rise to costiveness, that can be removed only 
by correcting the position of that organ. It is not sufficient to know 
that the patient does not have regular operations from the bowels, 
but we must know why she is thus constipated : whether on account 
of want of secretion, and, if so, of what secretion ; whether it is at- 
tributable to general debility, combined with muscular weakness of 
the intestines, or to lack of irritability of the intestinal tube and con- 
sequent torpor ; and if so, whether this lack of irritability exists in 
the whole length of the canal, in the colon, or the rectum. We must 
also know whether there is obstruction from stricture in the rectum, 
piles, thickening in the mucous membrane, rigidity of the sphincter, 
or from the uterus bearing heavily upon it. To give a laxative merely 
because it ordinarily produces a fecal discharge, is always unphilo- 
sophical, and sometimes exceedingly injurious in its effects. I think 
it is inattention to the exact state of the alimentary canal that makes 
constipation so often incurable. For constipation, attended with very 
dry. hard stools, showing a deficiency in all the secretions from the 
bowels, in addition to the course of diet, including acid fruits, etc., our 
object should be to administer such drugs as will most effectually stimu- 
late to secretion. The various saline medicines are indicated. Sul- 
phate of magnesia is a most excellent one ; and a good way of admin- 
istering it is in combination with sulphuric acid. From one to two 
drachms, or even half an ounce, given in combination with acid 
enough to taste somewhat sharply, will promote secretion along the 
whole of the small intestines, cause a large effusion of water, which 
will dissolve the faeces and render their evacuation easy and sure. In 
the morning, some time before eating, is the best time to take it. When 
there is reason to believe that the portal circulation is slow, and the 
liver furnishing less than its usual amount of secretion, some form of 
mercurial should be used with the salts. If the case is chronic and 
the constipation obstinate, we may give from six to ten grains of blue 
mass in pills, at bedtime, every fourth or fifth night, and follow it 
with Epsom salts in the morning. A continuance of this alterative 
cathartic from four to six weeks, seldom fails to cause a change in the 
alimentary secretions. Sometimes it is better to give these cathartics 



CONSTIPATION. 409 

nearer, and sometimes farther apart. We must judge of this more by 
the susceptibility to the constitutional influence of mercury than any 
thing else. It is almost always the case that this very scanty state of 
the secretions is accompanied with an impoverished state of the blood ; 
hence iron in some shape will be beneficial in most cases. If there is 
much debility, a long course of tonics will be indispensable. It may 
often happen that this scanty condition of the secretions is attended 
with debility of the muscular fibre of the intestinal canal. When 
this is the case, we must add to the above treatment that which is ap- 
plicable to this kind of intestinal torpor, which I shall now consider. 
Before doing so, however, I will remark that several other salts will 
answer as well, and sometimes even better, than sulphate of magnesia. 
The kinds of tonics which are most effectual in debility of the muscular 
structure of the intestinal canal are such as give general strength, and 
it is most desirable to combine them with special tonics. The latter 
are rhubarb and nux vomica. These have always seemed to me to 
have a special tonic influence upon the intestinal tube, and, when 
properly given, to increase the susceptibility to their own action. The 
rhubarb, although an alimentary tonic, induces less susceptibility to 
its own influence than the nux vomica. The best way to give the 
rhubarb is either in the root, without pulverization, or in the extract. 
When given alone in the root, the patient can take a little, twice a day, 
by chewing, and, after mixing with the saliva, swallowing it. A little 
experience will enable the patient to judge of the right quantity , which 
she can repeat as often as it is required. When the rhubarb is taken 
this way, she may also take a solution of ferri sulph. and strychnia, in 
water, one grain of the former to one-sixteenth of a grain of the 
latter. 

I have often succeeded in overcoming this constipation or debility 
by giving one grain of quin. sulph. with five grains of powdered nux 
vomica after each meal. Or the same amount of nux vomica, with 
iron by hydrogen, two grains each time, after eating. It is usual to 
use aloes in the constipation of uterine diseases ; but I have found 
very few cases with which this drug did not disagree. But there is 
a torpor of the intestines where general tonics cannot be borne; 
where, in fact, there does not seem to be any general debility, there 
is only a want of susceptibility to the stimuli which ordinarily arouse 
them to action. The secretions color the fseces properly, and give 
them sufficient moisture ; there seems to be no fault in their appear- 
ance, consistence, odor, or other character whatever. They are de- 
ficient only. The patient may be plethoric and florid, her general 
muscular strength sufficient, and her blood, so far as we can judge, 
good in composition. Special tonics and stimuli are indicated in 
such instances, and they alone should be used. Such measures should 
be adopted as will arouse the muscular action of the intestines. Nux 



410 GENERAL TREATMENT OF UTERINE DISEASE. 

vomica, in five-grain doses, with the rhubarb extract or without it, 
or the strychnia in solution, in doses from a sixteenth to a twentieth 
of a grain, constitute our most valuable medicinal remedies. This 
is the kind of constipation that is most benefited by and is most 
amenable to a persevering regiminal and dietetic course of manage- 
ment, such as I have endeavored to give. 

In addition to the rhubarb and nux vomica treatment, we may get 
some good from external appliances, and manipulations of the walls 
of the abdomen. The most valuable, when gently, perseveringly, 
and methodically applied, is what is understood by the term knead- 
ing. The colon is the torpid portion in most cases of this sort of 
constipation. The process of kneading consists in handling it so as 
to stimulate its fibres directly. One plan is to grasp it with the hand, 
and squeeze it from one end to the other. We should begin at the 
right groin, and with a knowledge of the position and direction of it, 
grasp it with both hands at this point, then a little higher up on the 
same side, and then a little higher, until we reach the right hypo- 
chondriac region. We should then follow it across the abdomen to 
the left hypochondriac region, and thence down to the left iliac. Or, 
we may double our hands as bakers do when kneading their dough, 
and standing over the patient, press with the knuckles of both hands, 
first in the right iliac region, and imitating the process of kneading, 
pass slowly from this to the right hypochondriac, thence across the 
abdomen and down, as before directed. If we trust this process to a 
non-professional attendant, we should be sure to show him how to do 
it, as it is important that it should be done right. When this process 
of kneading or squeezing the colon is first instituted, it should be 
practiced with the utmost gentleness, but the force and rapidity of 
motion may be increased until great freedom may be used. It should 
be resorted to a short time before retiring to the water-closet, say half 
an hour. Some patients find an efficient laxative in what they some- 
times call a water-compress, applied to the abdomen overnight. It is 
made by doubling a napkin several times, so as to make a thick com- 
press, large enough to cover the entire abdomen anteriorly. This is 
saturated with water, and, after being placed upon the abdomen, 
covered with a roller or bandage so as to keep it in place. It is thus 
allowed to remain from the time of going to bed until the time to rise 
in the morning. I think this water-compress is best adapted to cases 
in which there is a deficiency of secretion in the intestinal tube. 

A bandage, or, what is better, a roller applied tightly enough to 
press the wall strongly upon the contents of the abdomen, frequently 
stimulates them to proper action, both as it respects secretion and 
peristalic motion. When it is determined to use the roller or band- 
age for its stimulating influence, it ought to be applied upon rising 
in the morning, or, what is perhaps better, immediately after break- 



CONSTIPATION. 411 

fast. This bandage should not be worn constantly, nor even many 
hours in the day. From the time of rising until two hours after 
breakfast, or from breakfast for three hours thereafter, will be long 
enough. The constant use of the bandage would but increase the 
evil — lax abdominal muscles — for which it is advised. Before leav- 
ing this part of the subject, I desire to say, with reference to the free 
use of nux vomica to overcome intestinal torpor, that in all cases we 
should remember its effects are cumulative, and quite a difference of 
susceptibility to its influence is manifested by different persons, in 
consequence of which the patient should be watched, and the dose 
graduated to the least quantity necessary in the case. Although I 
have given nux vomica and strychnia for a considerable length of 
time to a great variety of persons, and for several weeks together, I 
have never seen anything more than slight inconvenience from it in 
the shape of nervous startings. Very rarely we meet persons who 
cannot take it at all; it disagrees with them as soon as they commence 
its use. 

There is another species of intestinal torpor of a very obstinate 
character and very distressing to the patient ; I mean a lax ; torpid 
rectum ; so torpid as to allow the faeces to accumulate in large quan- 
tities, and cause great inconvenience from pressure. To such an ex- 
tent does this collection sometimes go as to press the posterior wall 
of the vagina forward and protrude it between the labia. The first 
indication in such cases is to dissolve the fecal mass and discharge it. 
Various kinds of injections are useful for this purpose, warm oil, 
warm water, etc. ; but one which I have seen do much good is com- 
posed of one ounce of fresh ox-gall and four ounces of warm water. 
This composition dissolves the faeces very readily, and the fresh bile 
stimulates the intestines to their expulsion. The evacuation, of course, 
will give only temporary relief, and there remains the most important 
indication, that of giving tone to the bowels, with a view of prevent- 
ing the accumulation in future. This is difficult, and in some in- 
stances of long standing quite impossible. Much good can be done 
in nearly all cases, however, and we do not discharge our duty if we 
do not try to relieve when we cannot cure. Cold water thrown into 
the rectum once or twice a day, in small quantities — eight ounces — 
is always good, without some special reason to the contrary. There 
are generally two indications to be fulfilled in these cases, — relaxation 
of the sphincters and restoration of the tonicity of the proper rectal 
fibres. 

It is a singular fact, which I think I have observed, that the 
sphincter muscles increase in strength with the advance of age ; this 
is one of the causes why the fasces are voided with more difficulty in 
old persons. To give tone to the rectal muscles, astringent injections 
have been recommended and extensively used ; but in my practice 



412 GENERAL TREATMENT OF UTERINE DISEASE. 

they have been almost uniformly useless, many times injurious, and 
always disagreeable. They dry up the secretions, an evil not to be 
compensated for by any other effect; they do not, so far as I can 
judge, cause contraction of the muscular fibres, but they are very 
apt, if persisted in for a length of time, to cause inflammation. I 
have derived more benefit from tonic suppositories and injections 
than from any other kind of medicinal treatment. A suppository 
of twenty grains of extract of gentian, or five grains quin. sulph., ten 
grains of extract of cornus Florida, or a mucilaginous suspension of 
any of these introduced into the rectum every night at bedtime, and 
retained, if possible, until morning, are good tonics and eligible 
modes of using them. It will be necessary, to secure the retention 
and efficient contact of these tonics, to first empty the bowels with 
ox-gall and warm water, and afterward introduce them with as little 
irritation as possible. The quantity of mucilaginous material should 
not exceed two ounces. The tonic treatment of this kind must be 
varied, taking first one tonic and then another, in first one form and 
then a different one, and must be kept up for a long time to do much 
good. We cannot be too careful, in all our treatment, to avoid any- 
thing to which the rectum shows any sensitiveness. When it be- 
comes tender and sensitive, we should at once desist until all of this 
has subsided before we are justified in beginning again. It too fre- 
quently happens that both the physician and patient become dis- 
couraged, and desist before the remedies have had a fair trial. Is 
there anything that will relax the sphincter ani? I am not aware 
that any means operate with efficiency in this direction ; but I have 
used, in a few instances, with apparent benefit, the ointment of bella- 
donna, made by mixing the extract with lard. I apply it to the 
anus externally upon going to bed at night, and continue it, until 
the question against or in favor of its usefulness is fully determined. 

This application certainly removes the irritability of the sphincter, 
which causes it sometimes to resist the extrusion of the fasces. 

As I have before remarked, there are cases in which this relaxation 
cannot be cured ; we are then compelled to resort to palliatives, and 
we must be careful to palliate intelligently. We are to give the weak 
rectum artificial support, to enable it to retain, as near as may be, its 
ordinary size. This can be done only through the vagina. An air or 
sponge pessary introduced into the vagina, so as to press the rectum 
against the sacrum, and thus diminish its capacity, will prevent the 
great accumulations from taking place, and in that way prevent one 
source of great inconvenience. Dr. Hodge recommends the globe 
pessary for this condition of the rectum, which answers very well in 
many cases, perhaps in the majority ; but each case must be studied 
with reference to its own peculiarities, and the shape, size and con- 
sistency of the pessary adapted to it. 



CONSTIPATION. 413 

When our object is palliation alone, there is no objection to wearing 
the pessary all the time, but if it is used to palliate what we believe to 
be a curable case, we ought to use it intermittingly, and the patient 
should not wear it at night, especially. It would probably be better, 
in a majority of the cases, to introduce it before rising in the morning, 
and allow it to remain until noon. One thing I think essential in the 
size and position of the pessary, and that is, that it does not compress 
the rectum below its natural capacity ; there should be room enough 
for an ordinary amount of faeces in it, lest it become a source of ob- 
struction, which it will do when larger or improperly placed. 

As will be noticed, I have omitted to say anything of enemata in con- 
stipation, from inactivity of the colon or upper portion of the alimen- 
tary canal. As an occasional means injections operate well ; but like 
other laxatives, when used for a length of time they lose their influence 
entirely. If we determine to use injections as an habitual laxative, 
by proper changes in kind and quantity, we may prolong their efficacy 
very much. To a person unused to them half a pint of cold water will 
act very well. When the bowels fail to respond to this quantity there 
ought to be an increase of two or three ounces, and then that amount 
used until its effects are not satisfactory, when a few ounces more 
should be added, and so on we may increase the amount until the 
quantity becomes intolerable. When this is the case we may order 
half a pint of water with a drachm or two of common salt, chlorate 
potassa, or nitrate of soda or potassa. We should increase the quan- 
tity of water, or strength of solution, or both, as the susceptibility of 
the rectum is decreased, until we cannot carry either farther. In very 
obstinate constipation the bowels may be emptied with much cer- 
tainty by injecting a large quantity of water in the knee-chest posi- 
tion. In this position the water will pass the sigmoid flexure of the 
colon into the mass of faeces, softening it, and, by its bulk, stimulate 
the alimentary canal to expulsive efforts. Very few cases will resist 
this method of administering enemata. After we have thus obtained 
as much good from injections as we can, it is sometimes expedient to 
use suppositories as laxatives. Suppositories are made of laxative 
medicines, or of any other material. Compound extract of colocynth 
or some other purgative extract may be used ; or we may enclose in 
some of the extracts a dose of podophyllum, or any of the purgative 
resinoids or alkaloids. These should be retained until absorption 
takes place. The common suppositories of soap, tallow, wax, sperm, 
stearin, etc., are of the second kind. It not unfrequently happens that 
the above modes of using injections and suppositories may be alter- 
nated very profitably, the full effects of each being experienced upon 
their resumption after having used the other for a time. But some 
persons cannot use injections ; the rectum is too sensitive, and attempts 



414 GENERAL TREATMENT OF UTERINE DISEASE. 

to do so induce so much irritation that they must abandon them. In 
such cases suppositories are out of the question. 

This form of rectocele sometimes requires a resort to surgery. The 
operation is detailed elsewhere. 

I have elsewhere shown that the uterus, by its wrong position, some- 
times presses upon the rectum and obstructs the passage of the fseces. 
This may be effected by retroversion or prolapse. The indication, of 
course, is to restore the uterus to its proper place, and as we shall have 
occasion to speak elsewhere of these difficulties (malpositions), I do 
not think it necessary to more than mention them here. 



CHAPTEE XXII. 

SPECIAL TREATMENT. 

Baths. 

The local treatment of inflammation of the cervix uteri is made 
up of several therapeutic items, varying according to the intensity, 
quality, and seat of disease. Of these there are, however, a few that 
are applicable to almost all cases ; hence their description, modes of 
use, etc., may be considered before going farther. Baths, injections, 
and some minor remedies are of this kind. Water, when applied to 
the surface, is purely sedative in its effects if it is of the temperature 
of the part on which it is used. If the bath is partial, the sedative 
influence is for the most part confined or limited to the part to which 
the application is made. So with injections per rectum or vaginam. 
They soothe the parts contained in the pelvis. If the water is warmer 
than the part of the surface bathed, the effect is stimulant; if it is 
colder, by virtue of the physiological action brought into play, it is 
first sedative and then stimulant. The circulation and nervous influ- 
ence of the vagina, for instance, when the cold water is first thrown 
into it, are depressed, but very soon after its evacuation, or with- 
drawal, the vessels become excited to increased circulation of blood, 
and increased heat takes place and the nerves become more sensitive. 
In all these respects baths and injections act alike. The injections 
are internal baths, by which the uterus is bathed through the vagina. 
But the effects of baths and injections may be modified by containing 
medicinal substances. They may be rendered more stimulant or 
more sedative, or be even made to possess other qualities by impregna- 
tion with medicines ; one in very common use is astringent in char- 
acter. Another mode of using water and applying it, either simple 
or impregnated with medicine, is, to wet a cloth or a sponge with it 
and bind it to the surface, or introduce it into the vagina. Several 
thicknesses of cotton cloth applied to the abdomen and impregnated 
with water is what is called the water compress; and often when 
allowed to remain in contact with the skin for several hours it pro- 
duces considerable excitement, and, if persisted in for days, will 
cause first a vesicular, next a pustular, and finally a phlegmonous 
eruption. The way to render it effective is, after applying the wet 
cloth, to cover it over with oil-silk, and then confine the whole with 
a bandage or roller, with a view to prevent evaporation. Sponge in- 
troduced into the vagina, impregnated with water holding medicine 



416 SPECIAL TKEATMENT. 

in solution, is a common way of affecting the uterus. I do not design 
giving an extended view of the effects of baths or their application 
and modus operandi, but so much aid is occasionally obtained by the 
use of them, that I cannot refrain from speaking of the application of 
some forms of them to diseases of the uterus. 

Hip-bath. 

The bath most applicable in inflammation of the cervix uteri and 
most commonly used is the sitz- or hip-bath, which is intended to 
allay the inflammatory irritation and pain. It is often the case that 
there is a great deal of suffering from pain without much inflam- 
matory action in the parts ; in these cases a sitz-bath will often give 
great relief. In many instances the efficacy of the bath may be 
enhanced by having the patient introduce a speculum while in the 
water, so that it may pass up the vagina to the neck of the uterus and 
thus directly affect the part diseased. In cases of medicated sitz- 
baths the organ may thus receive the full benefit of the saline, ano- 
dyne, or other medicinal impregnation. The common glass tube will 
do very well for this use, where we wish only to bathe the neck of the 
uterus ; but if we wish the fluid to come in contact with the vaginal 
walls and remain there for a considerable time, the wire speculum is 
the best. While speaking of the use of the speculum in this way, I 
may mention that a very efficacious mode of applying medicated 
washes without the bath to the cervix uteri or vaginal walls, is to 
have the patient, lie upon her back, introduce the speculum, and then 
pour the fluid into it. By remaining in that position she can retain 
the contact of the medicated solution as long as desirable. Ice-water, 
ice, astringent powders, or almost any form of substance may be ap- 
plied and retained in contact with the os and cervix uteri with great 
advantage in this way. This mode of using remedies is particularly 
useful in bleeding fungus or vascular tumor of any kind. 

The sitz-bath, when a patient is suffering with the pain and heat 
of uterine disease, may be used as often as necessary, twice a day at 
least ; but three, four, or even a greater number of times will not be 
too often, when they are found to be soothing and useful. We may 
extemporize a hip- or sitz-bath, by putting water in a common wash- 
ing-tub; but the cheap tin vessels made for the purpose are within 
the command of almost all persons. There should be so much water 
that when the patient sits down in it, the whole pelvis will be covered. 

Temperature of the Bath. 

What should be the temperature of the bath? The patient's sense 
of comfort or discomfort from its use should be our guide in this 
respect. We should seek a temperature that is comfortable an . 



VAGINAL INJECTIONS, IRRIGATION, DOUCHES. 417 

soothing to the patient while in the water, and that leaves no sense of 
discomfort. The baths are intended for, and should add to, the com- 
fort of the patient; when they do not do this, they should at once be 
discontinued. As a general rule I advise my patient to take tepid 
water for her first baths, and then gradually use them cooler until 
they are cold, unless they become disagreeable in some respect ; if 
they do so, to continue them tepid. The colder a bath is the more 
good it does, provided it be comfortable. The time for taking it may 
be regulated by the convenience of the patient, and the necessity for 
it, with the view of allaying pain, heat, etc. ; probably in the majority 
of instances, the most advisable times for taking it are upon rising 
and retiring. The length of time the patient remains in the bath 
should also be regulated somewhat by its effects. If the patient 
remains too long in the water it will debilitate her, particularly if 
there is considerable water and the bath is frequently repeated ; on 
the other hand, if she does not remain long enough, she will not de- 
rive any benefit from it. She may try remaining in it fifteen minutes, 
if she does not find herself very much relieved before that time, and 
she ought to be governed in her use of subsequent baths in this 
particular by the effects of the first few trials. While in the bath the 
intended temperature of the water may be kept up by adding hot 
water from time to time. The hip-bath is used almost wholly with 
reference to the local disease, but when general baths are required, 
it is usually for the relief of some attendant general symptom. 

Shower-bath. 

The shower-bath may be used as a roborant excitor of the circula- 
tion, if upon trial it can be borne, and produce a good effect. Some 
patients think they are very much benefited by the shower-bath, and 
say they cannot do without it. 

Sponge Bath. 

The sponge bath is useful in causing a tonic and soothing reaction 
upon the surface. Neither of these can be tolerated by very feeble 
patients. The cold or tepid sponge bath, administered at bedtime, 
not unfrequently soothes nervous irritability, and enables restless 
persons to sleep soundly. I have not used baths in any other form 
than these, but when used as I have here indicated, I have seen such 
pleasant results from them that I cannot refrain from recommending 
them. 

Vaginal Injections, Irrigation, Douches. 

The modern methods and purposes of vaginal injections differ so 
much from the imperfect ones used only a decade since, as to require 
new means as well as modes. In early gynecology we satisfied our- 

27 



418 



SPECIAL TKEATMENT. 



selves with the glass or hard rubber instruments, not much longer 
than a man's ringer. Another step toward the present condition of 
things brought us the soft rubber tube of some length, and a bulb 
with which to keep up a perpetual stream. This was a laborious in- 
strument, and required strong muscle to use it. Next came the 
fountain syringe, holding a quart at first, afterwards two quarts. _ This 
was a labor-saving machine, and was an approach to luxury in the 
use of douches. During all this time the patient took her injections 
in the sitting posture. Now the fountain has grown to great dimen- 
sions, holding gallons, and it is indispensable that the patient assume 
the dorsal recumbent position, which necessitates the douche-pan and 
slop-bucket. 



Fig. 202. 






Vaginal Douches. 



At first the purpose was to medicate the vagina and cervix ; after- 
wards to cleanse, or medicate, or both. Now the purpose is to treat 
the parts to a very hot bath, with the object of stimulating the capil- 
laries of the mucous surfaces, causing their contraction, and restricting 
the flow of blood to the inflamed parts, and to influence the deeper 
tissues by a similar effect upon their capillaries. This amounts to a 
valuable alterative to the parts within reach of the effect of the heat 
in the water. The influence of the hot water when the patient is lying 



ACCIDENT IN INJECTION. 419 

on her back, is complete by filling the vaginal cavity and keeping it 
so by furnishing a continuous supply from the fountain as long as is 
desirable. Injections, or more properly, douches, of hot water are 
applicable to a large variety of cases — chronic inflammation in the 
vagina and cervix, and cases of inn ammatory exudation in the pelvic 
tissues outside the uterus. In acute cases of inflammation this hot 
water cannot generally be borne ; and many patients cannot tolerate 
it even when the conditions indicating it seem to be present, probably 
on account of some peculiar susceptibility. Some patients will profit 
by a small amount of hot water and suffer from the large douche. 
Others will be comforted and improved by the use of tepid water in 
large or small quantities, who cannot use the hot. The apparatus for 
using the douche consists of two pieces, a large reservoir of tin or 
rubber, and a douche-pan. The douche-pan may be made of rubber, 
tin, or earthen material, and resembles an ordinary bed-pan furnished 
with an outlet tube to carry the water into a bucket, basin, or other 
receptacle. 

These large douches are used twice a day or oftener as they may 
appear to be useful or not. 

Accident in Injection. 

There is one annoying, and sometimes to the patient alarming, 
little accident that occasionally occurs during the reception of an in- 
jection in the vagina. Suddenly, while injecting the fluid, she is 
seized with severe cramping pain in the hypogastric region, which 
radiates to the back and hips, down the thighs, and sometimes over 
the whole abdomen. She becomes sick at her stomach, is attacked 
with rigors, and her feet and hands often become cold. This pain 
continues, with exacerbations and remissions, for several minutes or 
hours, and when it subsides, leaves a sense of soreness, more or less 
considerable, corresponding with the severity of the attack. As the 
chilliness and rigors of the first few moments subside, there is reac- 
tion ; the patient becomes warm, and sometimes decidedly feverish. 
In all cases in which I have witnessed these symptoms the patients 
were using a syringe in the end of which, within the vagina, were 
several perforations, some on the side of the bulb at the end, and one 
at the very extremity. I think that one of the perforations had been 
accidentally placed in opposition with the external os uteri, and as the 
water was forced through this perforation, it entered the cavity of the 
cervix, and passed through into the cavity of the body of the uterus, 
inducing the first shock, and the pains following it were caused by the 
spasmodic attempts on the part of the uterus to expel it. Although 
I have, in a large number of instances, been called upon to witness 
and prescribe for these symptoms, I have not seen them proceed to 
dangerous extremities. I think these are cases of injection into the 



420 SPECIAL TREATMENT. 

womb; and, in this respect, they constitute my whole observation. 
An opiate injection per rectum, fomentations over the pubis, and 
quiet, are all the remedies I have found necessary. And often the 
symptoms subside so soon that I have not been under the necessity of 
prescribing at all. 

We occasionally meet with patients who cannot use baths or injec- 
tions. In these cases it will be found, almost invariably, that this 
inability arises from their producing an exaggerated effect. If it 
is simple tepid water used for the bath or injection, its results are too 
sedative. The bath debilitates the patient, instead of simply sooth- 
ing her. I have seen a single tepid bath prostrate a patient so that 
she would have to lie in bed for several hours before its effects wore 
off. A cold bath induces chilliness and permanent coldness, and re- 
action is not established; the system recovers from its effects only 
after a number of hours, and that slowly. Hip, sitz, or general 
baths may produce these effects, and when they do so, should be 
abandoned as injurious. Other nervous symptoms, as difficulty of 
breathing, nausea, dysuria, etc., also occasionally seem to be the 
effects of baths. It is singular that some patients are so susceptible 
to the depressing effects of water that injections debilitate them very 
rapidly, and they are obliged to abandon them on this account. Cold 
water, as an injection, not unfrequently causes general coldness. But 
it is the medicated injections that most frequently produce an exag- 
gerated effect. Alum injections, even when the solution is weak, with 
some patients, produce such disagreeable and constant dryness, and 
sense of heat, as to make them quite intolerable. And the sensitive- 
ness of the vagina becomes so great that some patients are forced to 
cease the injections of alum wholly. The same objections apply to 
other astringents to a less degree, and the consequence is, that how- 
ever baths and injections may seem to be indicated, in the cases where 
idiosyncrasy renders them so objectionable, we must forego their use 
entirely. 

Should they be used in Pregnancy ? 

Is pregnancy an objection to the use of local baths and injections? 
I think not with proper care. A hot bath about the hips would be 
objectionable ; a very cold bath that might cause much of a shock, or 
internal congestions, would not be advisable; but plenty of tepid 
water, and even cool water, temperately used as baths, give the preg- 
nant woman great comfort, and cannot generally be followed by any 
bad effect. Injections may be used with less caution than baths. The 
caution which we would administer to all is, that they should not be 
copious. In pregnancy the patient ought not to use more than a 
quart at one time. The injections should always be tepid or cool ; 
not very cold or very warm, lest they stimulate the muscular, vascu- 



INJECTIONS IN PREGNANCY. 421 

lar or nervous system of the uterus too much, and induce hemorrhage, 
or provoke contractions. Both of these effects, I think, I have known 
produced by such injections ; the cold causing contraction and expul- 
sion ; and the very warm hemorrhage and death of the ovum. Strong 
astringents should also be avoided. Much comfort may be derived 
from anodyne injections, when there is neuralgic suffering about the 
uterus or vagina, during pregnancy. Cases of superficial inflamma- 
tion, and even early ulceration of the vaginal portion of the cervix, 
may always be benefited by injections, baths, and the general treat- 
ment which I have heretofore detailed. In fact, most cases, if not all, 
where there is no idiosyncratic objection to the baths and injections, 
will be very much benefited by them. When, however, the disease 
has been of long standing, or extends between the labia of the os uteri, 
or into the cavity of the cervix, these will only slightly benefit it. We 
must then seek for something that will more profoundly influence 
the nutritional changes, and the vascular and nervous tissues of the 
parts. 

The introduction of anodyne, astringent and alterative ointments, 
pessaries and powders may be resorted to with much profit in many 
instances. The small instrument called the suppository syringe will 
enable the patient to place ointment in contact with the uterus very 
conveniently. Ointments made with opium, belladonna, hyoscyamus, 

Fig. 203. 




Ointment Syringe. 



cicuta, tannic acid, mercury, iodine — in fact, almost any substance 
used to exert an influence locally — may be made into ointment and 
thus introduced. The powders of many of these articles may be 
deposited in the vagina in the same way. And the medicated pes- 
saries made by mixing the medicine intended to be used with cacao- 
butter, may be passed up to the os uteri through a glass speculum, 
either by the patient, her attendants, or the physician. In using the 
narcotics in the vagina, in the form of ointment or pessary, we can 
safely use double the quantity given by the stomach. The ointment 
is absorbed slowly, and consequently it requires some time to effect 
much by it. But the powders act much more readily. Morphia thus 
introduced will sometimes act with great promptitude, and the powder 
of tannic acid is a ver}^ efficient astringent used in this way. The 
absorbing power of the vaginal mucous membrane is decidedly less 
than that of the rectum. It takes a longer time and more of the medi- 
cine to affect the system through this cavity. Possibly this may be 
to some extent on account of the more ready escape of substances 



422 LOCAL TREATMENT. 

from the vagina; but I think, also, the membrane does not take up 
substances so quickly. From this fact injections or suppositories per 
rectum will often do more good in allaying pain especially than when 
used per vaginam. A few drops of strong solution of morphia sulph. in 
the rectum act very promptly. Dr. Greenhalgh and others use cotton 
pessaries medicated, per vaginam. The cotton is prepared by immers- 
ing it in a strong solution of the medicinal agent to be employed, and 
afterward drying before using it. Still another method of making 
local applications to the upper part of the vagina is to envelop the 
medicines in a sac of thin cotton or linen goods, and pass it up to the 
cervix, and let it remain there until the astringent, or whatever may 
be contained in it, is dissolved out, and exerts its influence upon the 
parts. The patient can use this kind of application without assist- 
ance. 

LOCAL TREATMENT. 

There are very few cases of chronic inflammation and congestion of 
the uterus that may not be benefited by what is known as local treat- 
ment. This is especially true with reference to those cases in which 
the intensity of the disease is sufficient to cause the loss of the epithe- 
lium or deeper portions of the mucous membrane, — abrasion or ulcera- 
tion. Local treatment is not only beneficial but indispensable to the 
cure of endometritis and endocervicitis. 

Local treatment consists in the application of certain medicines di- 
rectly to different parts of the uterus and vagina for the relief of the 
various conditions connected with the inflammation. The medicines 
and the methods of their application are intended: first, to relieve 
pain by their anodyne influence; second, to deplete the parts of the 
superabundance of blood ; and, third, to change the character of the 
capillary circulation by restoring its natural activity. 

When there is much pain of whatever character the anodyne appli- 
cations are indicated ; and many patients will bear anodynes as local 
applications for the relief of pain very much better than when taken 
internally. Even where there is no idiosyncrasy forbidding the use 
of anodynes, they may affect the stomach on account of their taste, so 
that they cannot be borne or will not be taken. 

Suppositories made by impregnating cacao-butter with a quantity 
of the anodyne to be made fifty per cent, larger than when taken in 
the stomach, and repeated as frequently as required, is one method 
of making anodyne applications. The suppositories are made by the 
apothecary in a shape and of a size for the vagina, and also for the 
rectum. It requires a longer time for the anodyne to be absorbed by 
the vaginal membrane than by the stomach or rectum. 

When it is desired to use the suppositories in the rectum instead 



LOCAL TREATMENT. 423 

of the vagina, it will require no more than the ordinary dose of the 
medicine, and the effect is obtained more promptly. It must be re- 
membered also that the mucous membrane of the rectum is very much 
more sensitive than that of the vagina. When therefore we desire to 
use medicines, the primary effect of which is irritation, as chloral or 
bromides, it will be necessary to dilute them more than for the vagina. 
Topical applications of anodynes may be made in various other ways, 
by inclosing the medicines in a sac of thin cotton cloth, gauze, or do- 
mestic, and placing it in the upper part of the vagina, or entangling 
it in cotton-wool and putting it near the cervix. 

Sometimes the medicine may be applied in solution, the patient 
lying on her back so that the fluid may gravitate to the cervix. Half 
an ounce of fluid introduced through an ordinary glass or rubber 
syringe will generally be retained — if the patient continues the dorsal 
position — until it affects the nerves of the part. Applications of this 
kind can be made by the patient herself, or the nurse. 

.Topical depletion in inflammation and congestion of the uterus is 
also a most valuable curative measure. When the uterus is very 
tender and sensitive to the touch, it will require but little irritation 
to cause intense local inflammation. We must be especially careful 
under such circumstances to avoid the third class of topical applica- 
tions. 

The tenderness and sensitiveness depend upon an unusual intensity 
of inflammation in the fibrous structure of the uterus above, which, 
although chronic in duration, is subacute in grade. The kind of 
turgidity, sensitiveness, and pain is sometimes kept up by the pres- 
ence of perimetric inflammation — cellulitis — local peritonitis, cystitis, 
etc., and they contraindicate any stimulating applications to the 
uterus. It is in the conditions just described that local depletion is 
applicable and beneficial. Common means of local depletion are 
leeches and scarification. Leeches may be applied directly to the 
uterus through the speculum, around the anus, over the sacrum or 
pubic region. When we desire to apply them to the cervix, some 
preparation will be necessary to insure success. The vagina must be 
thoroughly washed by large injections of hot water to remove any 
offensive secretion or other contents of the vagina. The cervix may 
then be exposed by the speculum and sponged with sugar and milk, 
and it will add to the readiness with which the leeches take hold to 
prick the cervix until it bleeds, and then smear the surface with the 
blood. The leeches are first thrown into tepid water, and from it are 
taken out, placed in contact with the cervix, and watched until they 
fasten upon it. The number employed — from four to twelve — will 
be governed by the amount of turgescence and pain ; when the in- 
tensity of inflammation is very considerable, the greater number. In 
judging of the number necessary, we must be governed By the pain, 



424 LOCAL TBEATMEXT. 

tenderness, and general condition of the patient. The pain and 
tenderness must be such as are caused b} 7 " local hyperemia— inflam- 
matory or congestive — or by inflammation in the surrounding tissue, 
and not the pain and sensitiveness of neurotic conditions of the parts 
or the patient. I do not mean neuralgic pain as that term is generally 
understood, but hyperesthesia unattended by any hypersemia. 

Scarification cannot be made to take the place of leeches, but it is 
often followed by great improvement, and is very efficient in remov- 
ing congestion of the submucous tissues. It may be performed by 
any long pointed knife by which the cervix can be reached, but 
perhaps the more efficient instrument is Buttle's artificial leech. It 
is a very small spear-shaped knife mounted upon a long shank and 
handle (Fig. 205). With these instruments, the most dependent parts 
of the cervix may be pricked in several places. The bleeding may be 
encouraged by injections of tepid water in large quantities. 

Fig. 204. 



Knife for Scarifying the Cervix. 

In what time of the month is depletion the most useful ? Before 
the commencement of the flow, as a rule, there is the greater amount 
of hyperemia, and consequently is the time we might effect the most 
good from depletion. This is not always the case, however. There 
is no question that patients who have febrile excitement daring the 
time of the antemenstrual congestion are very much benefited by 
local depletion at that time, but much more frequently the cases of 
lingering congestion will require it oftener. 

When the menstrual flow is deficient and the uterus is not relieved 
by it, many women are relieved by leeching or scarifying the cervix. 

The congestion which lingers after the menstrual period and causes 
so much suffering, is generally, although not always, the result of a 
very scanty flow. In either case, when we determine to deplete, it 
should be done as early as the close of the flow, at latest, and if the 
flow is scanty during the discharge. 

Independent of these j)hysiological reasons for selecting these times 
for depletion, and notwithstanding the fact that thus used the deple- 
tion is generally attended with the best results, the very best rule for 
our guide will be found in the symptoms. In most cases there is a 
particular time in the month when the symptoms are the greatest in 
intensity ; that is the time to deplete. In some this intensity occurs 
before, in others during or immediately after, the flow, while in still 
another class of patients it is midway between the periods. Rarely 
there are chronic cases where the congestive or inflammatory symp- 



LOCAL TREATMENT. 425 

toms last all the time. When there is enough general vigor, these 
will be improved by depletion two or three times a month. 

In connection with the measures for depletion, glycerin deserves 
to be mentioned. When placed in contact with the surface of the 
body, its strong affinity for water attracts the serum of the blood from 
the capillary bloodvessels very rapidly. This process is very much 
more active in the vaginal cavity, where the air is to a great extent 
excluded, as the whole capacity of the glycerin to take up moisture 
is exerted upon the membrane by which it is surrounded, and a large 
quantity of serum is rapidly abstracted from the diseased parts. The 
tumefaction and tension are at once removed and the pain relieved. 

When a glycerin tampon is placed in the upper part of the vagina, 
it requires but a few minutes to establish a copious watery discharge, 
that lasts until the glycerin, diluted with several times its own weight 
of serum, is washed out and exhausted. 

The relief which follows this application of glycerin is often even 
more marked than after depletion by leeches. Glycerin was first 
used as a dressing in vaginal operations by Dr. Sims, and it required 
but a little time for him to discover its valuable properties as a means 
of relieving inflammation and congestion. Used in this way I con- 
sider glycerin invaluable. As a lubricant or solvent for local appli- 
cations I believe it to be worse than useless. To dissolve medicine 
in it, and then apply it to the cervix, is to insure the rapid removal 
of the medicine by a current of serum poured out from the surface. 
For this reason absorption from a glycerin solution, applied to the 
vaginal surface, is simply impossible. The efficacy of glycerin appli- 
cations depends very much upon their preparation and the method of 
using them. 

The best quality of cotton batting is the substance most appropriate 
with which to make glycerin applications. There is a great differ- 
ence in the grades of cotton batting in the market, and we should be 
careful to get the best article made. It absorbs a larger quantity of 
glycerin, and does not wad up into such a compact mass as an in- 
ferior article does. In preparing the glycerin cotton for use, it should 
be made into a round ball, about an inch and a quarter in diameter, 
when loosely pressed in the hand. This may be secured by passing 
a strong thread around it, having the thread long enough to bring 
out of the vagina, so that the patient may be able to remove it ; or 
the cotton may be rolled into the shape of a cylinder, two inches long, 
and one in diameter, and secured by a thread. Every piece to be 
used should be thoroughly saturated with the glycerin. It is not 
sufficient to impregnate the surface of the cotton ball with the medi- 
cine, but every fibre should be saturated with it. This requires some 
time to accomplish, and it will be well for office use to submerge the 
cotton in a jar of glycerin and let it lie until it becomes saturated. 



426 LOCAL TREATMENT. 

When we use these, if they are thus saturated, they may be gently 
pressed until the glycerin will not flow from their surface. 

The speculum will be necessary to a perfect application of glycerin, 
and the cotton must be placed in contact with the diseased surface. 
One or more of these pieces may be applied according to the capacity 
of the vagina or the amount of congestion. Glycerin thus used may 
be applied every third day, and if the cotton is well saturated, allowed 
to remain twenty-four hours, when it should be removed. 

Cotton treated with glycerin in this way is not fit for a support to 
a disj:)laced uterus, and too frequent use of these applications is occa- 
sionally followed by a sensitiveness of the mucous membrane that 
renders them intolerable. 

It is not often that we rely upon glycerin applications for a cure, 
or even as the principal remedy. It is more commonly used as an 
adjuvant or a palliative measure to follow stronger applications. 
When we are under the necessity of making a strong application to 
the cervix and vagina, to follow it immediately by glycerin prevents 
the severe consequences that sometimes follow. 

Local Alteratives. 

The many remedies applied to the inflamed and abraded surfaces 
of the cervix, while they fulfil the general indication of changing the 
action of the nerves and vessels of the parts to which they are applied, 
their special effects are not precisely the same. There is certainly a 
wide difference between the local effects of tannin and nitric acid, of 
tincture of iron and nitrate of silver. Yet we find them all, and 
many others, used in the same kind of cases, one or two of them re- 
garded as quite sufficient to cure a large majority of cases. This is 
the case with iodine, carbolic acid, and nitrate of silver. The prac- 
tice of experienced gynecologists, in the use of these local remedies, 
is remarkable in the fact that a very few can agree upon the same 
articles. To the inexperienced this is perplexing; but it is account- 
able for by the consideration that anything which will excite the 
vasomotor nerves sufficiently to increase the sluggish capillary circu- 
lation,— an essential item in the process of congestion and inflamma- 
tion, — will induce a change in the morbid tissue to which it is applied. 
Astringents, stimulants, caustics, etc., have this effect, and so will the 
mechanical influence of friction or pressure. This consideration does 
not justify indifference as to the choice of local applications, for there 
are other differences than degrees of intensity in their action. There 
is, therefore, room and reason for selections, which will give quite a 
range in our choice. We should continually bear in mind that all 
irritants applied to the cervix as local applications, produce their 
effect upon the vasomotor nervous system primarily, and, secondarily, 
upon the circulatory and absorbent functions of the vascular system, 



LOCAL ALTERATIVES. 427 

and that in consequence of the unity of the vasomotor nervous appa- 
ratus of the cervix and body of the uterus, any impression made upon 
the neck is reflected upon the body, and conversely. The reflected 
influence is felt not only upon the vessels, but also upon the fibrous 
structure of the uterus. This explains the effects of therapeutical 
measures applied to the cervix. 

There are also certain remedies which, when applied to the cervix, 
exert an influence through the blood. Mercury and iodine are un- 
questionably absorbed, and they may have a double influence upon 
the local disease, first, by the direct stimulating effect upon the nerves 
of the part, and secondly, by their well-known general alterative in- 
fluence. I have several times seen a marked ptyalism follow a single 
moderate local application of the solution of pernitrate of mercury, 

Fig. 205. 



Dr. Buttle's Uterine Scarificator and Leech, very efficient and convenient for abstracting 
blood from the engorged cervix uteri. 

and it is not an uncommon thing for patients to complain of a me- 
tallic taste in the mouth in a very short time after an application of 
iodine or mercury. When thus they obviously enter the circulation, 
they may be expected to exert the same influence upon the effusion 
in the substance of the cervix and body of the uterus as if taken 
internally. 

Locally iodine, in the form of the ordinary tincture, Churchill's 
tincture, and other alcoholic solutions, is a very strong stimulant, and 
is scarcely caustic in any of these solutions. It is, therefore, in these 
forms, an excellent application when we desire to produce a strong 
but superficial effect upon the mucous membrane of the vagina, cervix, 
or cervical cavity, and should not be repeated often. A solution made 
by dissolving one part each of iodine and iodide of potassium in one 
part of alcohol makes a very efficacious application, made by a swab 
once in a week or ten days to the erosions of the cervix, connected 
or not connected with laceration. Applied in this way they excite 
the capillary circulation of the whole uterus to recuperative activity, 
and thus cure up the erosions and cause the absorption of the deposit 
in the areolar tissue. Iodine again is used in a different way and for 
another purpose; that is, in a non-irritating form, in which it may 
be absorbed and expend its influence as an alterative through the 
circulation. It is often dissolved in glycerin and applied on cotton 
to the cervix. The solution of iodine in glycerin for an application 
is almost, if not entirely, useless, so far as the iodine is concerned, for 
it is very soon washed out of the vagina by the serum drawn from 
the parts by the glycerin. 



428 LOCAL TREATMENT. 

The very best way to obtain the fullest alterative effects of iodine as 
a vaginal application is to impregnate cotton-wool with iodine by 
mixing the crystals of iodine with the cotton, and then placing them 
in a well-stoppered bottle in a moderately warm place, when the 
iodine will become volatilized and diffuse itself thoroughly and uni- 
formly in the cotton. This cotton may be applied through the specu- 
lum to the cervix, and allowed to remain there for twenty -four hours. 
This application may be used every fourth or fifth day. 

It is a very common practice to combine iodine and other medi- 
cines for local applications. Iodine and carbolic acid, called iodized 
phenol, are combined in the proportion of one part of iodine to four 
parts of carbolic acid. This mixture is a favorite one with Dr. Robert 
Battey, of Rome, Georgia. He has written an able paper * detail- 
ing its effects in endometritis. His endorsement of it, as a local appli- 
cation in this form of disease, is a sufficient guarantee of its useful- 
ness. 

The solution of pernitrate of mercury (acid nitrate of mercury), be- 
cause of its valuable alterative influence, deserves particular notice. 
Unlike iodine, it is strongly caustic and can be made to destroy the 
parts to a great depth. In this respect, perhaps, it is about equal to 
nitric acid. The application of these remedies, however, can be made 
without destroying the tissues; and now that we know the salutary 
influence of our applications does not depend upon " burning off the 
ulcer," or cauterizing the abrasion, but that their efficacy depends 
upon the excitation they produce upon the submucous vessels, these 
medicines are used very differently. 

The acid nitrate of mercury should be applied by the cotton swab 
so lightly as not to cauterize. The cotton should be dipped into the 
mercury solution and saturated with it, and, before being applied, 
pressed firmly between two wooden surfaces until it is merely moist 
with the solution. The cotton thus prepared is applied to the surface ; 
it coagulates the mucus on the surface merely. The application in a 
few hours is followed by local reaction in the capillaries immediately 
beneath the part, which, in a certain degree, is salutary. It is not 
best to use this for congestion or inflammation, attended or not with 
abrasion, oftener than once in two weeks or a month. The second 
day after the menses is the best time. Carbolic acid, in solutions of 
various strength, is a popular remedy for local application to the 
cervix uteri. The 95 per cent, solution is equal in stimulating influ- 
ences to that of the nitrate of silver of 20 per cent, strength. If used 
exclusively, or as the main article, for stimulating the inflamed cervix, 
it may be applied once a week. 



* Read at the meeting of the British Medical Association for 1879, held at Cork, 
Ireland. 



TREATMENT OF ENDOMETRITIS. 429 

Among the astringents the preparations of iron, solution of the per- 
sulphate and the tincture of iron are frequently used. The tincture 
of iron, once in five or six days, is very generally used with great 
benefit. 

The nitrate of silver, once so popular as a topical application, has 
fallen into disrepute, and is seldom resorted to by our best gynecolo- 
gists. The main objections to it are the great pain it often produces, 
the intensity of the submucous capillary excitement it causes, which 
sometimes extends to the cellular tissue ; the amount of hemorrhage it 
often causes, and its severe effects upon the nervous system. But the 
most important objection to it, perhaps, is the shrinkage and conden- 
sation it brings about in the cervix. 

After it has been used with any thoroughness for a long time the 
cervix, and sometimes the uterus, is diminished in size and indurated. 
Although hemorrhage is a common symptom immediately following 
the application, it is not unusual that the protracted use of it leads to 
suppression, more or less completely, of the menstrual flow. It must 
be admitted, however, that these objections apply more to what, in 
our present knowledge of its effects, we would consider the injudicious 
application of it in solid form. In solution it may be made to pro- 
duce an alterative influence that is difficult to effect with any other 
remedy. 

A 50 per cent, solution, applied with the swab, is not a caustic, and 
is not amenable to the objections just above mentioned, and intended 
to apply to the solid form. 

Whatever the application may be, it should not be repeated if fol- 
lowed by evidences of serious irritation, as pain, lasting for over an 
hour; tenderness in the iliac or hypogastric region; chilliness or 
febrile excitement. 

When an application is made from which we expect any consider- 
able pain or reaction, the patient should lie down and remain quiet 
until all sense of inconvenience has passed away. 

As before remarked, we may frequently secure immunity from 
suffering by following the application with a tampon of glycerin 
cotton. 

Treatment of Endometritis. 

When the disease is confined to the cervical cavity the simpler 
forms can be cured by the same kind of application made use of in 
the treatment of ordinary inflammation and abrasion of the cervix. 
To make these efficacious it will be necessary to remove the mucus 
from the cervical cavity by wiping it away with cotton, when that is 
practicable, and, when not, it may be removed by a syringe. 

With the ordinary flexible applicator, wrapped with cotton, the 



430 LOCAL TREATMENT. 

remedy is passed into the cervical cavity up to the internal os uteri. 
The same precaution should be observed in other cases in which the 
application is made. 

The treatment of these simple cases is really not more difficult than 
when the disease is on the outer cervical mucous membrane. And 
as the external cervical inflammation, with erosions, coexists with 
the endocervical, they should both be treated at the same time, by 
first making the application externally, and then passing it into the 
cervical cavity. 

We sometimes meet with an obstinate yet uncomplicated form of 
endocervicitis, or cervical catarrh, that resists all of the usual remedies. 

The cervix is filled with an extremely tenacious mucus that is re- 
moved with great difficulty, the cavity of the cervix is enlarged, and 
when the mucous membrane is exposed may be seen to be very rough, 
granulated, and scarlet red. The granular eminences are the enlarged 
muciparous glands, the glands of Naboth. Dr. Sims* reports cases of 
this kind cured by thoroughly scraping the cervical cavity with a 
sharp curette, and afterwards touching the surface lightly with the 
actual cautery. Dr. Isaac E. Taylor, of New York, says he has re- 
sorted to this treatment with great success. 

When the inflammation extends to the cavity of the body of the 
uterus the treatment is more difficult of accomplishment, attended 
with less satisfactory results, and sometimes followed by severe symp- 
toms. 

When it is uncomplicated, and the cervical canal at both extremi- 
ties is patent, the treatment is generally simple and efficacious. The 
applications adapted to this form of disease are the same as for endo- 
cervicitis and are made in the same way. The applicator charged 
with the remedy is carried to the fundus, and by a gentle rotary 
movement made to touch the whole endometrium. 

Ordinarily these applications are not very painful. This form of 
endometritis, when the cervical canal is sufficiently open, may also be 
successfully treated by the dull-wire curette. This instrument may 
generally be passed with great ease, and, after it is introduced, it is 
gently passed over the whole surface of the cavity. This can be re- 
peated once a week if necessary. 

I could report several cases where the curette used in this way has 
done more good than any other remedy used, and apparently com- 
pleted the cure. 

The curette in these cases is used, not for the purpose of cutting 
away any portion of the living membrane, nor for removing growths 
or granulations, but for the purpose of stimulating the circulation in 
the mucous membrane. 

* Transactions of the American Gynecological Society, 1879. 



TREATMENT OF ENDOMETRITIS. 



431 



When endometritis is complicated, the treatment will of course be 
very much modified by the complicating circumstances. Stenosis 
from contraction is a very inconvenient complication, because it must 
be overcome temporarily at least before our applications can be made 
complete. 

In this form I have frequently succeeded by using the slippery-elm 
tent. The tent can be made to overcome the stenosis and at the same 



Fig. 206. 




Slippery-elm Tent. 



time exert a salutary influence by pressure upon the mucous mem- 
brane of the uterine cavity, and thus suffice to effect a cure. 

The slippery-elm tent is made about one inch and a half, or one 
and three-fourths long, and the sixth of an inch in diameter at the 
large extremity, and small enough at the other to pass through the 



432 



LOCAL TREATMENT. 



narrowest place. Every tent should be securely fixed by threads so 
that it cannot be lost in the cavity, and may be easily removed. 

When we use them we thoroughly moisten them for two-thirds the 
distance from the extremity to be introduced. This moistening may 
be done in a moment by dipping them into water and then pinching 
and bending them. 

The part thus moistened should be soft enough to bend in any di- 
rection with very slight force. When the cervix is exposed we take 
the dry end of the tent in our dressing forceps and pass the moistened 
end into the uterus. The pliability of the tent enables us to pass it 
easily into the most tortuous canal. After having passed one, if we 

Fig. 207. 




Slippery-elm Tent introduced. 



are not satisfied, we may introduce one by the side of it, and then 
two, three, four, or a dozen, until we have dilated the canal suffi- 
ciently. These may be allowed to remain several hours if necessary, 
to cause further dilatation. But often they may be removed at once, 
and the cervix will be large enough to receive an application. I 
know, however, from frequent trial that no other application is neces- 
sary to cure many cases of endometritis. 

When I introduce one or two tents, in cases where stenosis com- 
plicates endometritis, I instruct the patient to remove the tent by 



TREATMENT OF ENDOMETRITIS. 



433 



drawing upon the thread whenever it gives her decided pain, and to 
not let it remain more than twelve hours if it does not give her pain. 
This is by far the most comfortable way of dilating, and according 
to my observation, the most effective. The slippery elm has the ad- 
vantage of being inexpensive and easily procured. In ten minutes 
the practitioner can make a dozen with his pocket-knife, out of the 
dry bark found in any drug store. When used in this way, and for 
this purpose, the dilatation is very moderate, but by repeating it be- 
comes permanent more readily than by the use of any other means. 
I can say further that I have had no bad results from slippery-elm 
tents when used in this way, and in those exceptional cases alone 
where a mere touch of the probe is painful do I apprehend the pos- 
sibility of harm. It is the safest means to dilate the cervix now in 
use, and when several are introduced by the side of each other they 
may be made to dilate the cervical cavity in a few minutes. 

Fig. 208. 




The Uterus in a state of Anteflexion, with the Slippery-elm Bougie introduced into it. 

This tent also may be made to shield the cervix from the effects of 
the pressure of the more energetic dilators. If we wish to dilate the 
cervix largely we may pass a sea- tangle or sponge tent, and then fill 
the cervical cavity around it by slippery-elm tents. 

As the sea-tangle or sponge expands, the elm tents shield the deli- 
cate mucous membrane from contact with the hard tent, and when the 
time comes to remove it there will be no difficulty in getting it away. 
Complicating misplacements, especially retroversions, should be cor- 
rected as an indispensable item of treatment. After the correction is 
made the treatment will not differ in any respect from the uncompli- 
cated case. > 

Flexions are more embarrassing complications than displacements, 

28 



434 LOCAL TREATMENT. 

because the point of greatest flexion is stenotic. Sometimes the ste- 
nosis is so great that it is difficult to pass a small sound. (Fig. 208.) 
The correction of the complication and the treatment of the inflam- 
mation may both be accomplished at the same time. These are the 
cases in which the slippery-elm tent will be of the greatest service. 
They are often attended with the dysmenorrhea of obstruction. We" 
can dilate and, to a certain extent, correct the flexion every time we 
make an application, by using one or two elm tents before introducing 
the application. But generally the tents, if allowed to remain in the 
cavity, as directed in the treatment of stenosis just described, will ex- 
ert a salutary effect by pressure. 

When the practitioner finds that a pessary can be used to advantage, 
it may be employed at the same time with the other treatment. 

When complicated by menorrhagia both diseases may generally be 
cured by the curette used as above directed. 

I have said nothing about intrauterine injections as a means of cur- 
ing endometritis. The subject has been very thoroughly discussed by 
the members of the profession, and few prominent gynecologists resort 
to this means in any form or at any time, except in the puerperal con- 
dition of the organ. For my own part, I have never injected the uterus 
for endometritis, and I do not hesitate to condemn it in such cases as 
dangerous, and yet there are those for whose opinions I have the high- 
est respect, who advise and employ injections, and speak of them as 
the most efficacious of all methods of applying medicines to the in- 
terior of the uterus. 

Professor James P. White,* of Buffalo, has invented a pipette of 
glass, bent to the shape of the uterus, with a bulb of india-rubber at 
the external end. He dips the end of the tube, which is very minute 
in size, into the fluid he desires to use, and then passes it through 
a speculum into the uterine cavity, and presses out in drops, or as 
much as he desires to leave there. The small quantity thus intro- 
duced he claims cannot, and does not, give rise to any grave symp- 
toms. 

In discussing the paper thus referred to, Dr. Munde, of New York, 
said : That he applies fluids to the cavity of the uterus through a very 
small flexible tube invented by Dr. Buttles, of New York. He thinks, 
cautiously done, this is a safe and efficacious way of treating the in- 
terior of the uterus. This method of using fluids in the cavity of the 
uterus can hardly be classed among injections, as the term has been 
heretofore understood. 

* Paper read before the American Gynecological Society, 1879. 



CHAPTEE XXIII. 

LACEKATIONS OF THE CEKVIX UTEEI. 

The consequences of this accident are so serious, and its occurrence 
so frequent, that it demands a prominent place in every text-book on 
gynecology. 

While many observers had noted the presence of lacerations of the 
cervix uteri, their importance until lately has been underrated ; they 
were thought, in fact, to give rise to no appreciable effects. 

This view was encouraged by the fact that a proper treatment of 
their consequences generally resulted in a temporary and sometimes 
permanent removal of the symptoms. 

Until Dr. Emmet made his remarkable researches upon the sub- 
ject, laceration of the cervix passed for one of the forms of ulceration 
and was described as ulceration of the cervix uteri. Now, however, 
owing to the enthusiasm of the discoverer, many of his students have 
gone to what I consider an unjustifiable extreme in the other direc- 
tion, expressing their opinions that, instead of everything being called 
ulceration, the proper term is laceration of the cervix. 

To Dr. Emmet belongs the credit of first appreciating the impor- 
tance and appropriately treating this accident. 

It very seldom occurs to any man to have the opportunity of giving 
to the profession so complete a description of an abnormal condition, 
and to perfect the process of cure, so that there is left to others but little 
room for improvement. Yet this is the good fortune of Dr. Emmet. 

Causes. 

Laceration of the cervix occurs during labor or expulsion of the 
contents of the uterus in abortion. Sudden expulsion of the head in 
cases where the cervix is not dilated sufficiently may eventuate in its 
rupture. 

It would be foreign to my purpose at present to discuss the various 
causes of the rigidity which prevents the ready dilatation of the cer- 
vix. They certainly are numerous and of frequent occurrence. Nor 
do I consider it necessary to criticise the early and frequent use of the 
forceps practiced by the accoucheur of the present day. The time has 
not yet come when the facts are at hand to justify such criticism. It 
is in order, however, to inform the obstetrician that his patients come 
to the gynecologist with laceration of the cervix in great numbers. 
Dr. Emmet finds laceration in about 16 per cent, of the cases coming 



436 LACERATIONS OF THE CERVIX UTERI. 

to him for treatment on account of uterine disease. Dr. Munde puts 
them clown at about 17 per cent., Dr. Montrose A. Pallen at 40 per 
cent., and Dr. Goodell says one in every six of his dispensary patients 
lias laceration of the cervix. My own observation confirms the 
opinion that these lacerations are of very frequent occurrence. Ob- 
serving the difference in virgin, as compared to the parous uteri, one 
must conclude that slight laceration from labor was the rule. 

Can extensive laceration of the cervix always be avoided ? This 
question brings to mind the frequency with which the perineum is 
torn under the management of the best practitioners, and the univer- 
sality with which slight laceration of that body takes place in 
primiparous women. 

The Degree, Locality, and Direction. 

The degree of laceration varies from the slight, almost inappreciable 
rupture to the splitting of the cervix into and above the vaginal junc- 
tion. It may be confined to one side, while the other retains its 
integrity, or both sides may be torn, one slightly and the other largely, 
or both to their utmost extent. 

The locality of the laceration is much more frequent in a line cor- 
responding to the junction of the anterior and posterior halves of the 
cervix, but sometimes the anterior or posterior lip of the uterus is 
torn in the centre in the various degrees above mentioned ; in others 
both the anterior and posterior lips are thus lacerated. In rare in- 
stances we find the two lateral and the two central lesions in the same 
cases, making the cervix project into the vagina with four points. I 
have seen one case where the anterior lip was split up to the vaginal 
junction, and then torn across to the left side, the portion torn hang- 
ing down into the vagina. 

Dr. Emmet thinks that the anterior and posterior labia are fre- 
quently torn, but from the direction of the vaginal pressure they 
generally heal up, and consequently do not often come under our 
observation. It is not unlikely, as he observes, that many lateral, as 
well as central, lacerations close up during the term of lying in, and 
therefore never give rise to any inconvenience. 

Effects of the Laceration. 

If we were guided by what we know of traumatic lesions elsewhere, 
as well as what we find in the cervix itself, we would, a priori, infer 
that inflammation was an early consequence of the accident. 

The torn edges, much more frequently than otherwise, become 
covered with cicatricial tissue, the result of inflammatory exudation, 
and a large amount of this cicatricial deposit is occasionally found in 
the angle of the laceration. Sometimes this last point of deposit 



COMPLICATIONS. 437 

presents a tough, hard node, that must be removed with great care 
to secure perfect results. 

This is not all the effects of the inflammatory action. Sometimes 
a fibrino-plastic exudation in the connective tissue of the two cervical 
flaps takes place, and they become large, dense, and hard. 

The surgeon will often find the cervix indurated so greatly that it 
resists the instruments, especially the passage of the needles; and he 
will find, as a rule, the more extensive the laceration, the greater will 
be this particular change, showing that they are all the seat of the 
most intense inflammatory action, and the converse. 

Another effect of the laceration on the parts is, at first, an inflam- 
matory action in the mucous membrane of the cervical cavity. 
Fibrino-j)lastic deposits occur in the deeper portions of the mem- 
brane, which becomes turgid and redundant; its epithelium is shed, 
and it presents a scarlet, rough surface. Sometimes the redundancy 
of the membrane is so great that it rolls out and forms a mass, fun- 
giform in appearance. 

As another consequence of this fibrino-plastic exudation, the mouths 
of many of the ducts leading from the glands of Naboth are closed, 
and the mucus of the glands is confined within their cystic cavities, 
or the whole gland is surrounded by the exudation and becomes in- 
volved in the hardened mass. Thus, in different cases, we find the 
glands presenting the appearance of translucent blebs or shot-like 
granulations. 

Effects on the Body of the Uterus. 

The inflammatory process going on in. the cervix, resulting from 
lacerations, arrests involution, and the uterus remains large and vas- 
cular ; in other words, in a state of subinvolution until the chronic 
inflammation is removed by proper treatment of the mucous mem- 
brane and submucous tissue, and the laceration closed by hystero- 
trachelorraphy. 

That lacerations which do not cause and maintain this uterine 
hyperemia are innocent of general disturbances, is admitted by Dr. 
Emmet, as I have shown elsewhere by quotations from his work.* 

Complications. 

Other embarrassing complications of laceration of the cervix are 
displacements, prolapse, and retroflexions, and lacerations of the peri- 
neum and vagina, and cellulitis and local peritonitis. These com- 
plications increase the hyperemia of the uterus, — retroflexion, by 
constriction of the cervix and consequent turgescence of that portion 
of the uterus with this ; and prolapse, by altering the direction of 

* Article on Subinvolution. 



438 LACERATIONS OF THE CERVIX UTERI. 

the veins which carry the blood from the uterus, augmenting the 
previously existing hyperemia of that organ. The uterus is thereby 
increased in weight, fibrino-plastic changes produced in its substance, 
and the nutrition of the mucous membrane of its cavity disturbed in 
a marked degree. 

Symptoms. 

The general symptoms following laceration of the cervix are not 
distinctive. That lesion produces, through its effects upon the body 
and cervix uteri, the symptoms given in detail elsewhere, under the 
head of Hysteropathy, and consequently need not be repeated here. 

Diagnosis. 

This cannot be made out by subjective symptoms alone, and we 
must depend upon a. thorough examination of the parts by the touch 
and use of instruments. By careful examination with the finger the 
notch in the side, when large, will be easily detected. The ringer 
should pass along the vaginal wall to its junction with the cervix, 
and keeping it in the cul-de-sac, passed all around so as to encircle 
the neck. 

In most instances, as the finger passes over the side, we will rec- 
ognize the fact that at that point the neck does not extend below the 
vaginal junction. The finger will sink into a depression between 
the labia. 

When the finger is educated in the vaginal touch, the lesion will be 
easily recognized. 

The sound will generally pass deeper into the body of the uterus 
than it will in the normal state of that organ, because the uterus is 
in a state of subinvolution. 

When well exposed by the speculum, the cervix will generally be 
found covered by a muco-purulent fluid, enlarged, the labia turned 
out, the exposed cavity of the neck intensely red, and the surface 
roughened in consequence of the loss of epithelium, and an enlarge- 
ment of the papillse and muciparous glands. The infallible test, 
however, is to seize the extremities of both labia with tenacula and 
draw them down together, somewhat forcibly. If the cervix has 
been torn on the side, the notch will be plainly seen. If there is no 
laceration, the cervix will be truncated instead of bifid, and the points 
of the tips can be drawn down only a trifling distance below their 
lateral junction. 

Treatment 

The treatment may be preventive, preparatory, and operative. 
The prevention of laceration of the cervix does not usually come 
within the province of the gynecologist. The obstetrician has charge 



PREPARATORY TREATMENT. 439 

of the patient at the time of the accident, and upon his skill will de- 
pend such immunity as can be secured by science. The probability 
is that it cannot be prevented in most instances in which it occurs, 
no more than laceration of the perineum can always be prevented. 
I can easily see how an early rupture of the membranes, a too early 
use of the forceps, or an ill-advised administration of ergot would 
favor laceration of the cervix. 

Now that their attention is called to the subject, obstetricians will 
no doubt soon be able to furnish the facts upon which may be based 
a judicious preventive treatment; at present it must be founded upon 
a rational view of the processes of labor. 

Preparatory Treatment. 

The treatment preparatory to an operation has been as fully devel- 
oped by Dr. Emmet as any part of the subject, and my experience 
corroborates the correctness of his teachings. 

The object of the preparatory treatment is to bring about a plastic 
condition of the parts to be united. This is accomplished by correct- 
ing any deviation from the normal state of general health by tonics, 
nutritious diet, exercise in the open air, promoting a soluble condition 
of the bowels with appropriate laxatives, etc. 

A robust state of the general health is an all-important part of the 
preparation in this as in all plastic operations. 

The local preparatory treatment consists, first, in placing the uterus 
in such position as is necessary to secure the greatest possible freedom 
of circulation, for the purpose of reducing the general hyperemia of 
that organ ; second, making use of such applications as will reduce 
the hyperemia of the uterus and cervix ; and, third, where there is 
induration from fibrino-plastic exudation in the connective tissue of 
the cervical flaps to as far as possible dissolve it out and bring about 
a normal condition of the structure. 

The first indication is met by a judicious use of pessaries of cotton, 
lint, and the closed-lever instrument.* The second, calls for the use 
of glycerin, cotton tampons, local bloodletting by puncture with 
Buttle's lancet-shaped knife, or other instrument which will answer 
the same purpose, and large hot-water injections. An employment 
of these means perse veringly for a sufficient length of time will be 
pretty sure to effect this object. The third will generally require 
more time, and is of equal importance with the other two. The ap- 
plications for this purpose consist in remedies that will stimulate the 
absorbents to the removal of the indurating substance. Dr. Emmet 
relies to a great extent upon Churchill's tincture of iodine for this 

* See Displacement. 



440 



LACERATIONS OE THE CERVIX UTERI. 



purpose. He applies it freely to the whole of the denuded mucous 
membrane about twice a week, followed by glycerin dressings. It is 
doubtless an excellent application. Occasional moderate dilatation 
by Peaslee's or Hanks 's dilators, often has a beneficial effect upon the 
cicatrized tissues high up in the cervix, and improves the circulation. 

When the gland cysts are large and numerous, Emmet pricks them 
with the lancet-shaped knife to void their contents and to deplete them 
of blood. 

In many cases of long standing, and where the pathological changes 
are greatest, the preparatory treatment will require to be employed 
for several months to secure the best results. In others of recent 
standing, and where the changes consist mostly of hyperemia, a few 
weeks will suffice. 

The Operation. 

To Dr. Dudley, of this city, is conceded the honor of first giving 
this operation an appropriate name, "trachelorraphy." Two or three 
days after the menses cease to flow is the best time to operate. 

Fig. 209. 




The Cervix with the Threads passed. 

The day before the operation it is a common practice, and I think a 
good one, to move the bowels pretty thoroughly by giving a laxative. 



THE OPERATIOX. 



441 



At the time of the operation I usually give the patient ether. This, 
however, is not absolutely necessary, especially in cases of moderate 
extent, as the operation is not very painful. 

The patient is placed in Sims's or Simon's position, and the vagina 
dilated as largely as necessary to bring the cervix into view. The 



Fig. 210. 




neck is then seized with a vulsellum forceps, and drawn down until 
the lips can be transfixed from before backward by a strong needle 
armed with a double thread. 

The threads are drawn through enough to form two loops, each 
through one of the labia, of sufficient length to pass several inches 



Fig. 211. 




Byford's Uterine Scissors. 



out of the vaginal orifice. With these loops of thread the cervix can 
be very completely fixed, and its position varied, as the convenience 
of the operator may require. The loops of thread may be held up by 
an assistant, subject to the direction of the surgeon. A small curved 
tenaculum forceps may be used for holding the cervix in position, or 
a strong double tenaculum. 



442 LACERATIONS OF THE CERVIX UTERI. 

When thus prepared the operator seizes the edge of the laceration 
with a tenaculum, and with scissors pares off all the cicatricial mem- 
brane. The denudation should be carried up into the angle between 
the cervical flaps and the wedge of cicatricial deposit thoroughly re- 
moved. In doing this care should be taken to cut off any irregularity, 
of surface on the edge of the laceration, so that the edges of the two 
sides may be brought into smooth coaptation. After the denudation 
is perfected, and the hemorrhage ceases, the stitches may be intro- 
duced. Beginning an eighth of an inch from the incision on the outer 
surface of the flap, the needle is passed perpendicularly through to a 
point that will include the same distance of the endo-cervical mem- 
brane. To the thread in the needle should be attached silver wire 
eight or ten inches long, drawn through and held by an assistant, 
until all of the wires are placed as in Fig. 212. Before twisting the 
wire the edges of the wound should be wiped clean of every small 
coagulum. If this precaution is not taken a clot of blood may be 
included between the united edges and prevent complete union. The 
wires may then be twisted evenly, as represented in Fig. 213. Pre- 
pared catgut, silkworm gut, and silk thread are equally as good as the 
silver wire. I now always use the silk thread. After the operation 
the vagina should be thoroughly cleansed and the patient put to bed. 

As the reader will see, this operation is a simple one, under favor- 
able circumstances, i. e., when the laceration is lateral, and does not 
extend above the vaginal junction. When it is stellate, or there is 
much loss of tissue, the ingenuity of the surgeon will be severely 
taxed. 

I am not informed as to the average number of successes in the 
operation of trachelorraphy, but I know that failures are not infre- 
quent, and it may be well to consider what are the reasons of failure. 

Among these reasons is an imperfect performance of the operation, 
but chief among them is imperfect preparation. 

The after-treatment is of great importance, especially for the first 
few days. The patient must remain very quiet and avoid all causes 
of vascular and nervous derangements. After this time there can be 
more freedom of motion. It is desirable that the bowels be not moved 
before the end of this time, when a laxative may be given, and means 
taken thenceforward to keep them in a soluble condition. If we do 
not conclude to prevent the evacuation of the bowels, we should ad- 
minister diet and saline laxatives to soften the faeces. 

It nas been usual to draw off the urine for the first four or five 
days, but this is not essential, as it is only necessary to avoid straining. 

The diet must be light, and for the most part liquid, for the first 
few days. 

The vagina should be kept clean by warm-water injections two or 
three times a day from the beginning to the end of the after-treat- 



THE OPEEATION. 



443 



ment. I have been in the habit of removing the sutures about the 
tenth day, but in the majority of cases they might be taken out on 
the seventh or eighth day. 

Fig. 212. 




The Mode of Passing the Sutures. 
Fig. 213. 




The Sutures Properly Placed and Twisted. 



CHAPTEE XXIV. 

OCCASIONAL UNTOWAKD EFFECTS OF UTEKINE MANIPULATIONS 
AND OPERATIONS. 

For the purpose of making the student understand the necessity of 
great caution and gentleness in examinations and operations upon the 
uterus, I subjoin a summary of the researches of Dr. George J. Engle- 
man, of St. Louis, on the subject.* 

Many of the cases mentioned by Dr. Engleman occurred in the 
hands of the most accomplished practitioners in different parts of the 
world. 

A simple digital examination of the unimpregnated uterus, in the 
hands of Nelaton, was followed by fatal peritonitis. 

Several cases of death from peritonitis were the result of the use of 
the uterine sound ; some because the sound perforated the uterine 
tissues on account of fatty degeneration rendering them soft and per- 
meable ; others without any apparent reason. 

There are also cases in which untoward results followed the use of 
vaginal injections of warm water. 

A number of deaths are recorded in which peritonitfs was caused 
by the use of sponge tents. One case is mentioned of severe perito- 
nitis from replacing the uterus by means of the sound. There is 
always more or less risk in this operation. Dr. J. M. Allen gives a 
case in which death was caused by the application of tincture of 
iodine to the cervix. 

Cellulitis has followed the application of various substances to the 
cervical and uterine canal. 

The danger of injections into the uterine cavity is shown by allu- 
sion to several cases of death in the hands of skilful gynecologists. 
The most trivial operations on the uterus or other organs in the pelvic 
cavity are sometimes followed by fatal results. Even scarification of 
the cervix has been the cause of fatal peritonitis. 

I have known of two cases of death follow incision of the cervical 
canal, and several others are mentioned in Dr. Engleman 's paper. 
Operations for lacerations of the cervix have been followed by death 
in several instances. The most careful removal of small polypi may 
be the cause of fatal peritonitis. 

Perineorrhaphy has, in a number of instances, been followed by 

* Paper read before the Missouri Medical Society, and published in September No., 
1880, American Practitioner. 



UTERINE MANIPULATIONS AND OPERATIONS. 44 5 

similar consequences. Stem pessaries, when incautiously used, are 
very dangerous instruments. 

It therefore appears that any kind of manipulation of the uterus or 
its lining membrane is, under certain inscrutable circumstances, liable 
to start an acute peritonitis. One of these circumstances, and per- 
haps the most frequent one, is the existence of an inappreciable grade 
of inflammation in the cellular or peritoneal structures immediately 
surrounding the uterus. 

Dr. Noeggerath * believes that latent gonorrhoea is very often the 
character of this lurking inflammation. 

It would seem that the use of sponge tents, intrauterine stem pes- 
saries, intrauterine injections, intrauterine applications, and cutting 
operations on the cervix uteri, were especially dangerous. 

We should exercise great care in all our manipulations of the pelvic 
organs, and leave no precautions known to gjmecology unemployed 
to avoid the dangers that occasionally present themselves when we 
venture upon the use of sponge tents, intrauterine injections, stem 
pessaries, or operate upon the cervix. Antiseptic precautions are al- 
ways advisable. 

* Gynecological Transactions, 1876. 



CHAPTER XXV. 

HYPERTROPHY OF THE CERVIX. 

Hypertrophy of the cervix is different from enlargement caused 
by fibrinous accumulation, and consists of an increase in the proper 
tissues of the organ. It is a real hypertrophy. Although not nearly 
so frequent as the enlargement from chronic inflammation, it is not of 
very rare occurrence. The s}*mptoms do not differ from prolapse of 
the uterus sufficiently to characterize it. The patient generally ex- 
periences a sense of bearing-down or weight on the perineum, pain in 
the sacral region, leucorrhcea, sometimes menorrhagia. and the various 
sympathetic symptoms already sufficiently dwelt upon of uterine irri- 
tation. 

Diagnosis. 

Upon examination the cervix is found hypertrophied and enlarged. 
There are two general forms observed so well marked as to entitle 
them to special mention. The first is such as we usually find in the 
nulliparous, an elongation of the whole cervix, and, some but not 
generally very great circumferential increase of size, and without 
much deviation from shape. This form is seen in Fig. 214. The next 
variety is an elongation and enlargement of the anterior or posterior 
labium, as represented in Fig. 215. I am not certain, from my own 
observation, whether this is always a pure hypertrophy or a mixture 
of this process with fibrinous infiltration ; probably the latter. 

The only appropriate treatment is amputation, and it is generally 
sufficient to remove all the disagreeable symptoms resulting from it. 
The plan I have usually pursued in removing this growth is by <:crase- 
ment. The chain of the ecraseur is passed around, at the place where 
the point marked out by the dotted line is seen in the figures, and the 
ratchet slowly worked until the division is complete. This operation 
is easily performed, and is perfectly safe when carefully done, and the 
parts cicatrize in a few days. An inconvenience mentioned by Dr. J. 
Marion Sims is encountered, in some instances, in amputating the first 
variety, viz., the contraction of the opening of the cervical cavity. It 
is an inconvenience, however, that is of no great importance generally, 
and may be remedied by making a small incision with a blunt-pointed 
bistoury immediately after the operation of amputation. Dr. Sims 



ELONGATION OF THE SUPRAVAGINAL CERVIX. 



447 



amputates the cervix with scissors. He exposes the organ with his 
speculum, cuts the parts squarely through at the dotted lines, and then 



Fig. 214. 



Fig. 215. 





Figures showing two Varieties of Hypertrophic Elongation and Enlargement of the Cervix Uteri. 
The Dotted Lines show the Proper Place for Amputation. 

draws the mucous membrane together over the cut surfaces with silver 
sutures. (Figs. 217 and 218). This lessens the size of the cut surfaces, 
and the parts heal more readily. 

Elongation of the Supravaginal Cervix. 

This condition of the cervix so completely simulates procidentia of 
the uterus that upon a superficial examination it may be mistaken for 
that condition. The elongated vaginal cervix with the vagina are 
protruded from the external parts. The vaginal walls are everted 
anteriorly and posteriorly, forming in most instances cystocele and 
rectocele. Sometimes the protrusion is less extensive, and the cervix 
alone protrudes from the external parts. 

The diagnosis is made by introducing the sound. That instrument 
will enter to a much greater depth than when the uterus is prolapsed, 
sometimes five or six inches. 

2d. By placing the patient in the knee-chest position. In this pos- 
ture the cervix very readily enters the pelvis and rises up to its normal 
position. If the sound is now introduced it will not enter the uterus 
to so great a depth. 

3d. By introducing the finger into the rectum while the patient is 
standing, we can feel that the length and shape of the uterus are 
greatly changed from the normal. The fundus and body will be 



448 



HYPERTROPHY OF THE CERVIX. 



found in situ, and from it the attenuated and elongated supravaginal 
cervix can be traced downward to its attachments to the vagina. 

This elongation of the cervix is called tensile elongation by Dr. 
Matthews Duncan, and, doubtless, as Dr. Goodell* believes, is the 
result of hypertrophy and stretching, instead of true hypertrophy. 
It would seem at any rate that the elasticity of the cervical tissues 
was very much increased, as in the erect posture, with the slight 




Supravaginal Elongatiori of the Cervix. 

weight of the relaxed vaginal walls and the bladder and rectum, the 
neck becomes elongated, and when the patient lies down retraction 
may soon follow. 

The vaginal portion of the cervix in most cases is considerably 
hypertrophied, and in respect to length and volume is much above 
the usual dimensions. There are other conditions in connection with 
tensile elongation of the cervix that have an important bearing upon 
the etiology and treatment. Almost all supports in the lower part of 
the pelvis are in a state of great relaxation, and. instead of being reten- 
tive, they contribute to the aggravation of the abnormal condition of 
the cervix. 

This is especially the case with the vaginal walls, the vesical liga- 
ments, connective tissue, and fascia. 

The perineum is either anatomically deficient from laceration, or 
destitute of that tonicity which makes it capable of resisting the pro- 

* Gynecological Transactions, 1879. 



ELONGATION OF THE SUPRAVAGINAL CERVIX. . 449 

trusion of the cervix. In contrast with this the supporting apparatus 
in the upper part of the pelvis retains its natural, if it is not endowed 
with more than normal retentive power. 

The treatment of this form of elongated cervix will depend some- 
what upon the time it has lasted, the extent of the elongation, and the 
relaxation of the perineum. 

"When the lesion is of recent origin, and the perineum has not been 
lacerated, and possesses a reasonable amount of resistance, we may 
hope to succeed in restoring the shape and size of the cervix by prop- 
erly supporting it with a pessary. In selecting an instrument for this 
purpose it will not often do to choose one that has its bearings wholly 
upon the perineum, but one that is partially maintained in position 
by external means. 

In the hands of most practitioners, I believe Cutter's or Scott's will 
fulfil the purpose more certainly than any other. While both of 
them rest upon the perineum, they may be so adjusted that they will 
not bear upon it with much weight. If, however, the perineum is 
in a lacerated or greatly relaxed state, we must depend, mainly upon 
surgical means, and as the result of my own observation, I do not 
hesitate to indorse the practice of Goodell as set forth in the paper 
above referred to, viz., to amputate the vaginal cervix and operate 
upon the perineum afterward if necessary. I do not consider it neces- 
sary to remove the cervix at the vaginal attachment, but think it 
better to leave a margin of one-fourth of an inch. Great care is neces- 
sary in removing the cervix in this condition to avoid wounding the 
bladder or opening the peritoneal cavity. 

Whether the amputation is done with scissors, knife, galvano- 
cautery, or ecraseur, we should take measures to secure ourselves 
against this accident. The most convenient way to do this is to pass 
two strong steel wires through the cervix slightly below the junction 
of the vagina and cervix. The wire or chain of the ecraseur may be 
applied close up to this wire ; this will prevent any traction upon one 
part more than another. The scissors may be used and the cervix 
amputated according to the method of Sims (Figs. 217 and 218), who 
draws the mucous membrane over the stump and unites it with four 
sutures, two on each side of the cervix. Hegar similarly unites the 
edges of the sides, but also unites the edges of the cervical mucous 
membrane with the vaginal edges opposite by two or three on the ante- 
rior, and the same number on the posterior cervical walls in the middle 
portion. The patient must remain in bed several weeks to secure the 
best results. Simon operated by cutting a wedge from each lip (Fig. 
219) and uniting the raw surfaces. This method is more applicable to 
cases in which the cervix is thickened as well as elongated. As there 
is often more or less cervical laceration, Emmet's operation for lacera- 
tion (removing plenty of tissue) is sometimes preferable to amputation. 

29 



450 



HYPERTROPHY OF THE CERVIX. 



When the perineum has been lacerated perineorrhaphy should be 
performed before the patient attempts to exercise on foot. 




Amputation of the Cervix— after Sims. 



Fig. 218. 




Amputation of the Cervix— Sutures Tied. 



If the perineum does not need restoration, and there should be any 
tendency to continuance of supravaginal elongation after the opera- 
tion, Scott's pessary should be introduced, to supply the support that 
the perineum in a healthy condition would give. 



Fig. 219. 










Simon's Method of Amputating the Cervix. 

Success in this operation will depend very greatly upon the treat- 
ment and care the parts receive for some time after the patient resumes 
the erect posture and her usual exercise. 



CHAPTER XXVI. 

ACUTE PERIMETRITIS. 

I use the term perimetritis to signify inflammation of the tissues 
surrounding the uterus, and include both cellulitis and local perito- 
nitis under this head. 

There is an abundance of areolar tissue in the pelvis. It is be- 
tween the bladder and pubis, the bladder and vagina, the vagina and 
rectum, but in greater amount between the sides of the vagina, uterus, 
and bladder, and the pelvic bones. (See p. 23, Figs. 7, 8, 9.) In a 
loose manner it fills up the space indicated. Within the folds of the 
peritoneum, the ovaria, the Fallopian tubes, and the round ligament 
are included with the cellular tissue. Inflammation attacks this areo- 
lar tissue not unfrequently on one side, and involves the tube, the 
ovary, ligament, and peritoneal covering ; less frequently both sides 
are simultaneously inflamed, and still less often that part between 
some of the hollow organs of the pelvis is affected, when we have a 
comparatively small point of disease, as, for instance, between the 
bladder and vagina, or this last and the rectum. This is perimetritis. 
There is a strong tendency when inflammation is lighted up. in any 
part, to spread to the space at the side of the uterus and vagina cov- 
ered by the broad ligament, on one or both sides. The inflammation 
is apt to run its course rapidly, as is usual in areolar tissue, either to 
resolution or suppuration, and as this tissue is abundant, and the 
organs in the pelvis easily moved, the effusive products are likely to 
be copious. In the first stage of inflammation, serum is rapidly 
poured out between the folds of the peritoneum by the side of the 
uterus and vagina ; it pushes these organs to one side of the pelvis, 
and forms a prominent inflammatory tumefaction at the side of the 
pelvic cavity, Avithin easy reach of the finger. This tumidity becomes 
harder in a short time, and forms a solid medium of connection be- 
tween the uterus and wall of the pelvis, indicating the change from 
serous to fibrinous effusion. Within a week or ten days, in very 
acute cases, in others from two to four, or even six weeks, the areolar 
tissue is broken down into copious suppuration. In some instances 
the suppuration does not advance beyond the stage of serous effusion. 
When, after lasting for an uncertain time, the symptoms begin to 
subside, the tumefaction disappears, and the patient soon recovers her 
health ; while in others it is arrested after fibrinous infiltration has 
cemented the parts solidly together. Although the symptoms are 



452 ACUTE PERIMETRITIS. 

moderated from their first acuteness when this is the case, some of 
them, as undue sensitiveness and sense of weight, and other kinds 
of pelvic distress, remain for a considerable time, and the patient re- 
covers from the attack very slowly, if ever completely. "When sup- 
puration takes place, if it is completely and readily evacuated, the 
patient very soon regains her health and strength. In some patients 
of broken-down or damaged constitutions, sloughing and extensive 
ulceration increase the damage to the organs. I once saw a syphilitic 
patient in whom extensive and rapidly spreading ulceration opened. 
the rectum, vagina, bladder, and, finally, the peritoneal cavity. Sup- 
puration in this case was unhealthy and ichorous, smelling strongly, 
and produced excoriation of the parts over which it flowed. If the 
evacuation of the pus is imperfect on account of opening into the 
rectum or bladder, and even in the vagina, the symptoms may be 
prolonged for months and even years. And in some cases where the 
evacuation of the pus and subsidence of the inflammation seemed 
complete, the disease recurs usually with diminished acuteness a num- 
ber of times. I once had a patient in whom an attack of perimetritis 
was contemporaneous with incipient pregnancy for four different times 
while under my care. In each one of these four times, the inflam- 
mation commenced at about the time the menstrual flow ought to 
have appeared after conception. Every time there was copious sup- 
puration, a free discharge of the pus, and, to all appearance, a com- 
plete recovery from the inflammation. The intervals were about two 
years in duration. I have seen three instances in which the recurrence 
of the inflammation had occurred at irregular intervals from three 
months to a year for over six years, another ten, and one as much as 
eighteen years. In this last case, the abscess was situated at the left 
side of the uterus, and usually after a week or ten days of acute suf- 
fering, it discharged about a half ounce of fetid pus, and then disap- 
peared, so that nothing but a slight induration at the point mentioned 
indicated any tendency to its recurrence. This chronic form. I think, 
is not very uncommon. I believe, also, that chronic induration in 
the spaces occupied by the pelvic areolar tissue, caused by fibrinous 
infiltration, not unfrequently presents itself as the effect of acute peri- 
metritis, producing many distressing symptoms, and rendering the 
patient liable to a recurrence of acute attacks. The extent of the in- 
flammation and tumefaction is governed somewhat by the condition 
of the patient. If she be in the puerperal state, the inflammatory 
excitement is likely to be greater, the swelling more extensive, and 
the suffering more severe, than if this condition is not present. Preg- 
nancy increases the intensity of the disease beyond what it is in the 
unimpregnated condition; the fever runs higher, and the extent of 
the inflammation is greater: The same will be the case after abor- 



CELLULITIS. 453 

tions. The mildest form of perimetritis is that which occurs in the 
unimpregnated female. 

When pus is formed, it finds its way out through several different 
channels. First, and most frequently, through the vagina ; the wall 
of the abscess nearest the vagina ulcerates through into this canal, 
and the pus escapes, first in small quantities, and finally freety, until 
the whole is evacuated; a number of days, and even weeks, may 
elapse before the discharge ceases and the cavity is filled up. The 
escape through the vagina is not only the most common, but this is 
the most favorable outlet, as the opening is generally pretty free and 
permanent. Second, in frequency, as the medium, of discharge is the 
rectum ; the pus makes its way into this intestine generally at the 
upper end of the septum between it and the vagina. The discharge 
is comparatively slow and unsatisfactory, appearing with the stools 
in small quantities, and continuing for a length of time. The open- 
ing into the bowels is almost, if not invariably, valvular and tortuous, 
permitting the escape with difficulty. If there does not occur a 
second opening into the vagina, the abscess will generate pus almost 
as fast as discharged, and we may expect times of partial relief and 
exacerbation for months and even years. I am acquainted with an 
instance in which the patient has not been entirely free from suffering 
from this cause for the last six years, and a number of times has been 
prostrated for weeks. But few days pass without the patient observ- 
ing matter in the fecal evacuations. The pus makes its way at other 
times through the inguinal regions ; sometimes it points in one of the 
labia, or burrows through the gluteal region. It also perforates the 
uterus or bladder, and follows the channels leading from them out- 
wardly. When the pus finds its way into any of these hollow organs, 
it causes severe irritation in them and efforts at expulsion. Dysuria, 
dysentery, and vaginitis are generally caused by it to a moderate de- 
gree, but sometimes the suffering from this cause in these organs is 
very great. But another mode of escape from the cavity of the ab- 
scess is into the peritoneal sac. This misfortune is comparatively 
infrequent, fortunate^, but invariably fatal unless relieved by lapa- 
rotomy. I have been unfortunate enough to be connected with two 
cases in which this untoward circumstance occurred. 

One of the patients was attacked in the puerperal state, and, after 
suffering for eight weeks with the inflammation of the tissues around 
the uterus, acute general peritonitis terminated her life in about 
thirty-six hours from the time it commenced. Upon examining the 
abdominal cavity, an opening was found near the left sacro- iliac 
junction, which communicated with the interior of the abscess, and 
several ounces of pus was in the cavity of the peritoneum, that had 
made its way through this opening. The usual lesions of extensive 
and acute peritonitis gave evidence of the cause of death. The other 



454 ACUTE PERIMETRITIS. 

case was in a sterile married woman, about twenty-five years of age, 
who had been treated three weeks for typhoid fever. Dissection 
revealed a large pelvic abscess, with recent rupture into the peritoneal 
cavity, and extensive peritoneal lesions. This overwhelming perito- 
neal inflammation lasted only about eighteen hours before the death 
of the patient. When the peritoneal symptom supervened, it was 
regarded as the result of the intestinal ulceration which sometimes 
so suddenly terminates typhoid fever. 

Causes. 

Perimetritis occurs as a sequel to abortions and labor at full term, 
and there is but little doubt but that these two conditions sometimes 
predispose to the disease. The menstrual congestion seems to do the 
same thing. Any circumstance that fills the pelvis with blood in 
active congestion may so predispose to it. Cold suddenly applied 
to the surface or to the feet and legs may excite the already congested 
parts into a state of inflammation. Much exercise of the limbs in 
walking or standing on them for a long time, when the pelvic vessels 
are already distended and excited, has, on some occasions, seemed to 
me to awaken inflammation. The incautious use of strong caustics 
to the cervix uteri may give rise to it. I think I saw a case in which 
perimetritis was brought about by severe exercise in walking imme- 
diately after the use of caustic potassa. Excessive venereal indul- 
gence predisposes to this inflammation, if it does not produce it alone.* 

Symptoms. 

The patient is attacked suddenly, usually with pain in the pelvis, 
hypogastrium, or iliac regions, which radiates to the sacrum, loins, 
and abdomen. Sometimes it passes down one extremity, or there is 
pain in both legs. The pain, generally at first aching and moderate, 
may become very severe, and darting or cramping in character. In 
the beginning, or after the inflammation has lasted a little while, 
there is pain or difficulty in urinating ; by pressing upon the inflamed 
parts, the passage of faeces through the rectum is painful. The patient 
usually experiences a sense of weight about the perineum, and drag- 
ging in the loins and hips. All the pains are much aggravated by 
motion, or assuming and continuing in the erect posture. Pressure 
over the epigastric and inguinal portions of the abdomen increases 
the pain and suffering. 

At the commencement of the pain the patient is attacked with 
rigors of greater or less severity. The chilliness may be slight, but 

* See Chapter XX. for other causes. 



CELLULITIS. 455 

often it amounts to severe shaking and trembling ; reaction propor- 
tionate to the intensity of the chill succeeds ; the head aches, the 
limbs are pained, the skin is hot and dry, and the tongue coated, and 
the mouth dry and parched. These symptoms may come on very 
suddenly, and the case be well marked in a few hours from the time 
they commence, or so moderately and gradually as to be several days 
in assuming prominence. In puerperal patients they occur generally 
several days after confinement, and seem to be induced by undue 
exertion or exposure. In such cases the symptoms are more intense 
than in the non-puerperal cases. The pulse is rapid, the nervous 
system much disturbed, the heat great, and often there is delirium. 
The high febrile excitement is attended with severe pain, extending 
in various directions. Tumefaction and tenderness over the lower 
parts of the abdomen indicate a local peritoneal inflammation in 
many of the more severe instances, although this is not always the 
case. Some of these puerperal cases so closely resemble cases of 
metroperitonitis — if they are not so indeed — that the cases are re- 
garded as attacks of puerperal fever. So intense are the symptoms 
as apparently to jeopardize the life of the patient immediately by 
the gravity of the general pelvic and abdominal inflammation. And 
when the tumefaction and tenderness of the abdomen subside, the 
febrile reaction is moderated or becomes more paroxysmal, we find 
a hard tumor generally on one side dipping down into the pelvis 
and extending sometimes to the ribs and across to the umbilicus ; 
or it may be developed in the mesial portion of the abdomen and 
pelvis, extending upward to a greater or less degree. Tumors of 
this kind are tender, and may be detected in the pelvis by a vagi- 
nal examination. They do not always suppurate, but generally 
disappear by absorption. At other times they produce copious quan- 
tities of pus. This inflammation sometimes dissects up the peritoneum 
over the osseous iliac, and lumbar muscles, to a great extent, dissolv- 
ing out the areolar tissue in a large space. The distension and ten- 
derness are quite frequently confined to one side, showing the point 
of greatest intensity of the disease, but we often find them extending 
entirely across, and sometimes considerably up the abdomen. These 
symptoms appertain to the first stage, and last for from four or five 
days to two weeks, and in rare cases longer, when they are gradually 
succeeded by those that indicate the suppurative stage. The pain be- 
comes less acute, and changes ordinarily to a burning character, quite 
as distressing, if not more so, than at first. It is worse at night, and 
prevents the patient from resting. The fever assumes something of a 
remitting type. It is more intense in the evening and night ; toward 
morning a moisture is observed upon the skin, the heat becomes less, 
and there is some amelioration in the suffering. After a little longer 
the paroxysms are very marked ; chilliness in the afterpart of the day 



456 ACUTE PERIMETRITIS. 

is succeeded by a very rapid pulse and intense heat of the surface. 
This fever lasts for six or eight hours, and is resolved by a copious 
perspiration. These perspirations are accompanied with great lan- 
guor and depression. The patient is debilitated and much worn by 
the continuance of the symptoms. At length, after days of this ex- 
hausting, suppurative fever, the pus makes its way through the walls 
of the abscess, and is discharged through some of the outlets men- 
tioned above. If the evacuation is free, and the discharge consider- 
able, the relief is very great indeed, the fever subsides, the perspiration 
ceases, the spirits are good, the appetite becomes excellent; in fact, 
the change in the patient is very great and gratifying. Convalescence 
is now established, and in a few days all the serious and distressing 
symptoms vanish. If the discharge is not free, and but a small quan- 
tity of the matter escapes, although there is relief, it is not so complete. 
The patient is temporarily better, but not convalescent. The opening 
is not sufficient, the pus continues to increase and imperfectly dis- 
charge, and fluctuations in the intensity of suffering continue to inspire 
hope and cause depression, until a freer opening occurs in the same 
place, or another one allows the pus to escape more freely. 

This description is intended to apply to cases of considerable in- 
tensity in the puerperal or non-puerperal patient. But the degrees of 
intensity are very different in different instances. Sometimes the 
symptoms are so slight as to scarcely attract attention, until the dis- 
charge begins to make its appearance. At other times there is dis- 
tressing fever, but the local symptoms are so poorly marked that the 
case is misapprehended. I have known the fever to last for three or 
four weeks, ending in hectic, with its exhausting accompaniments, 
before the true nature of the case was discovered. 

An example of the occasional insidiousness of the non-puerperal 
form of this affection is exhibited in the following case : 

Mrs. A , aged twenty-four, married two months, has suffered for 

the last four years with moderate dysmenorrhea, and occasional leu- 
corrhcea. Sexual intercourse has given her much pain from the first 
since her marriage ; after three weeks the pain in the coitus became 
intolerable. At this time she had severe pain in the back and pelvic 
region constantly, but not so severe as to prevent her being about in 
the attention to domestic duties and taking a short trip by rail with 
her husband. She had some very slight febrile reaction, with sense 
of chilling, for about twenty days, when the paroxysms assumed 
something of a hectic character, lasting from three o'clock until seven 
or eight p.m., terminating with copious diaphoresis. A little later a 
very severe pain in the hypogastric region was developed, attended 
with frequent efforts at urination. In about four days from the super- 
vention of this pain she began to pass pus in large quantities in the 
urine, together with marked quantities of blood. Upon making ex- 



CELLULITIS. 457 

am ination at this time the pelvis on the right side and front portion 
was filled by a tumefaction very tender to the touch, which had 
crowded the uterus back upon the rectum and down so that the os 
was in contact with the perineum. These symptoms and the exami- 
nation fully declared it a case of cellulitis. 

Diagnosis. 

Although the symptoms, in most cases, are severe and sufficiently 
prominent, they are not often distinctive. Several other affections 
resemble it in many symptoms. Hence, the only way to arrive at 
correct diagnosis is by physical examinations. The finger will be the 
only instrument necessary. It is cruel to use the speculum, while it 
affords us no aid in the vast majority of cases. I should not think it 
necessary to caution the reader against the use of this instrument if I 
had not seen it resorted to more than once, to the great torture of the 
patient. In making examinations for this kind of case, the patient 
should be so placed that we may use both hands if necessary. When 
one or two fingers are introduced into the vagina, they will detect un- 
usual tumidity in the pelvis. Sometimes this tumidity extends to the 
bottom of the pelvis on one side, and occasionally apparently fills 
up the whole lower part of the pelvic cavity ; at other times the tu- 
midity is circumscribed and confined to one side high up, or before 
the uterus. The tumefied parts are generally hard, and very tender 
to the touch, so that a small amount of pressure causes great suffer- 
ing ; the uterine neck is almost always pushed to one side, backward, 
upward, or downward ; the vagina is generally hot and dry, and all 
the parts sensitive. If we place one hand above the pelvis, while the 
fingers of the other are in the vagina, we will have a consciousness of 
a tumor between the fingers of the two hands. 

It is not always the case that any tumidity can be felt above the 
superior strait, but generally there is tumefaction in one iliac region 
or sometimes in both. The tumefaction may extend much above 
these regions, high up into the abdominal cavity, though not often. 
If the tumefaction is considerable, the uterus is firmly fixed in its 
place, but when less, this is not the case. In childbed patients we 
may distinguish cellulitis from peritonitis by digital examination per 
vaginam. There is not the hard tumefaction in the pelvis in the last 
as in the first. Tenderness and general distension of the abdomen 
are greater in peritonitis; the pulse is more rapid and is peculiar. 
These may and probably are often combined in puerperal fever, when 
the diagnosis is of less importance than when they are separate 
affections. The general peritoneal inflammation supervenes after 
delivery much earlier — generally on the second day — than any of the 
localized inflammations do. Cellulitis is more likely to attack the 



458 ACUTE PERIMETRITIS. 

patient when or after she begins to make exertion, or is exposed to 
cold several days, six to ten, and even more after delivery. (See 
Pelvic Peritonitis, p. 460.) 

From acute metritis in the puerperal or non-puerperal state, it may 
be distinguished by examination with the finger. There is not much 
difference in the mode of attack and history between acute metritis 
and perimetritis; but by a careful survey of the pelvic organs, we 
may separate the inflamed from the sound parts. In metritis the 
uterus is generally and symmetrically enlarged, and extends lower 
down in the pelvis, and if touched at any point is tender ; in cellulitis 
this organ is not generally enlarged, and if touched anywhere in such 
manner as not to press it against or move it on the side where the 
inflammation exists, is not the subject of painful impressions. The 
tenderness in cellulitis is generally to one side of the uterus, close to 
the walls of the pelvis. If the inflammation is in the badder, we 
may easily ascertain this fact, by pressing this organ between the 
fingers in the vagina and those above the symphysis pubis. From 
metatithmenia it is distinguishable by the tenderness and firmness of 
the tumor, the febrile symptoms, and the history of the two condi- 
tions; cellulitis being previously inflammatory, while metatithmenia. 
when inflammatory at all. becomes so some time after the commence- 
ment of the symptoms. The bloody tumor may be handled without 
much pain, is soft and yielding, and commences at the time of menstru- 
ating with sharp pain likened often to severe colic, without chill and 
fever at the beginning ; sometimes with collapse more or less intense. 
Carcinoma filling up the lateral parts of the pelvis, is sometimes 
mistaken for cellulitis, but more often the latter is mistaken for the 
former. Carcinoma is insidious in its incipiency. It has made great 
advance before symptoms indicate its existence, while cellulitis is 
heralded by inflammatory symptoms from the start. The hardness 
of carcinoma is greater, the tumidity more irregular and devoid of 
tenderness ; it is not hot as in inflammation. The discharge from 
carcinoma when it occurs is cadaverous in odor, thin and ichorous in 
character. In cellulitis the discharge is pus, and if it smells at all, 
the odor is faintly fecal. I have noticed this last feature in several 
instances of perimetritis, when the evacuation of the pus was free and 
copious through the vagina. 

The diagnosis from chronic metritis is not always easy. When 
cellulitis is chronic, it causes many of the symptoms which we ob- 
serve to be present in chronic metritis. It will require a careful 
consideration of the symptoms and history of the case, with physical 
examination. 

Chronic cellulitis ordinarily results from an acute attack, that was 
accompanied with a discharge of pus more or less copious, and par- 
oxysms of less intensity have succeeded, growing more mild, until the 



CELLULITIS. 459 

symptoms become obscure. Paroxysmal discharge of pus is a com- 
mon symptom of chronic cellulitis. Upon a thorough and careful 
examination of the pelvic cavity, we may find some small spot, not 
in contact with the uterus, but by the side of it ordinarily, that is 
hard and tender to the touch. In chronic metritis there is not always 
tenderness. 

Prognosis. 

This is generally favorable. There is probably more danger in 
attacks during the puerperal condition, or after miscarriage, than in 
unimpregnated patients, although the very large majority of these 
cases terminate favorably. Of course I leave out of this considera- 
tion such instances as are attended by general peritonitis of simulta- 
neous origin, and constitute only a part of the whole puerperal fever. 
I do not think there is much difference in the fatality of uncompli- 
cated cases occurring under these diverse circumstances. When cellu- 
litis proves fatal, it is generally in one of three ways: 1st. By ex- 
haustion caused by excessive and long-continued febrile excitement, 
symptomatic of extensive inflammation. 2d. The exhausting effects 
of hectic fever, diarrhoea, diaphoresis, and want of nourishment. 3d. 
Severe complications, arising during the progress, as peritonitis, by 
extension of inflammation; or the more rapidly fatal form of peri- 
tonitis, caused by effusion of pus in its cavity. I have seen three 
fatal cases. Two of them resulted from rupture of the abscess, and 
discharge of the pus into the peritoneal cavity. One of these was 
puerperal, and death occurred ten weeks after confinement; the other 
non-puerperal, and ended in eight weeks from the attack. The one 
which proved fatal from exhausing hectic, without evacuation of the 
pus, terminated in sixty days from the commencement. 

A great many cases terminate in the chronic form. The cause of 
this sort of termination is often incomplete evacuation of the pus, and, 
as a consequence, imperfect obliteration of the cavity of the abscess. 
The pus accumulates from time to time, and fresh eruptions, attended 
with a greater or less exacerbation of the symptoms, every few weeks 
or months, occur as this result. Or the external opening, wherever it 
may be, does not close, and there is a constant discharge of greater or 
less quantity, keeping up a kind of fistulous canal, leading generally 
some distance to the main seat of the difficulty. Or in still another 
sort of cases, the pus seems to be entirely evacuated, and the cavity 
obliterated, and there is nothing left but a small point of indurated 
tissue, which is the nucleus of inflammatory action under certain 
circumstances, as pregnancy, unusual excitement of the sexual organs 
from other reasons, etc. 



460 ACUTE PERIMETRITIS. 

Local Peritonitis. 

Post-mortem examinations, as shown especially byGoupel, demon- 
strate the fact that we may have peritonitis confined to the pelvis and 
its vicinity. Observing practitioners of long experience must have 
met with instances which, without any great difficulty, could be classed 
under this head, and I have no doubt of the practicability of generally 
distinguishing them from those of cellulitis, with which they are most 
likely to be confounded. 

Pelvic peritonitis is seldom primary and simple. More frequently it 
is primary, and leads to cellulitis as a complication ; and in other cases 
it is secondary, and a consequence of pre-existing cellulitis, and there- 
fore complicated with it. 

Post-mortem examinations are not always conclusive as indicating 
a condition which had existed during the entire course of the disease ; 
for while in the more acute stages there may have been coexisting in- 
flammation of the peritoneum and cellular tissue, the inflammatory 
action in the cellular tissue may have subsided, and the peritonitis 
alone remain to be discovered at the autopsy, and vice versa. 

This would mislead the pathologist who depended upon the post- 
mortem appearances entirely. 

When the peritoneum is primarily attacked, and the inflammation 
is confined to this membrane, it becomes injected with blood, dry, and 
rough, and in the motion to which the viscera are subjected during 
respiration, etc., the surfaces rub together and cause sharp stabbing 
pain. Upon the subsidence of this stage of the inflammation, an effu- 
sion of serum, rich in fibrin, takes place, which gravitates to the most 
dependent part, and usually accumulates in the cul-de-sac behind the 
uterus, but does not displace the organ to any marked degree. The 
effused fluid soon coagulates, and the liquid portion of the serum is 
removed by absorption, and there is a solid mass of fibrin left in the 
retrouterine pouch. 

If the uterus happens to be retroverted at the time of the coagula- 
tion, it is fixed in that position during the life of the patient or until 
absorption liberates it. 

The movements of the pelvic organs — and, by the way, these organs 
are always in motion in unison with the respiratory movements, and 
as an effect of the movements of the body — sometimes modify the form 
of the coagulum, drawing it out into bands, which stretch from one 
surface to the other. 

After this serous effusion, the inflammation may subside and leave 
the patient comfortable, but the subject of a fixed uterus. In some 
cases, however, the absorption is rapid, and the organ is left entirely 
free in a short time. 

Should the inflammation be more intense, the epithelium of the 



LOCAL PERITONITIS. 461 

membrane is loosened and falls off, leaving a pyogenic surface, from 
which pus is produced in greater or less quantities when there is a 
sero-purulent effusion confined in an irregular fibrinous capsule. 

If the pus is considerable in quantity an abscess is the result, which 
finds its way out in a manner similar to the evacuation of pus as a 
result of cellulitis. 

In the non-puerperal moderate cases of local peritonitis the serous 
and purulent accumulations are confined to the pelvic cavity, but in 
the puerperal or the more intense forms of non-puerperal inflamma- 
tions, these accumulations reach higher than the brim, and are often 
found in indurated patches in both iliac regions or over the hypo- 
gastrium. When these accumulations are round, or shaped like 
tumors, they may be mistaken for ovarian or uterine neoplasms. 

The Fallopian tubes are sometimes constricted by these fibrinous 
bands, and a portion of their cavity isolated, in which liquid accumu- 
lations collect, and give rise to Fallopian tumors, — hydrosalpinx. 

Bernutz and Goupil in some instances found the ovaries involved 
in the inflammation, and either destroyed by suppuration or left in a 
state of chronic inflammation. 

Causes. 

The puerperal condition at term, or after abortion, is a very fre- 
quent, if not the most frequent, cause of local peritonitis. 

The action of cold upon the woman, when the pelvic organs are 
in a state of intense congestion, just prior or at the time of menstrua- 
tion, is also a prolific cause. 

Gonorrhceal inflammation, by making its way through the cavity 
of the uterus and along the Fallopian tubes out upon the peritoneum, 
is, by common consent, taken to be another one of the causes ; but 
inflammation may, by contiguity, also extend from the uterus to the 
peritoneal membrane. This is the case, doubtless, in the puerperal 
condition, after the violence done to the uterus by severe labor or 
abortion, and in non-puerperal cases where strong applications have 
been made to it, operations, etc. 

Direct violence to the retrouterine portion of the peritoneum is 
often done by the injudicious introduction of foreign substances by 
the patient herself, excessive coition, and by rude and ill-directed 
attempts to replace the uterus by instruments. 

Symptoms. 

Pain in the 'pelvis and lower abdomen is one of the most common 
and distressing symptoms, and this pain is generally characteristic. 
It is sharp, stabbing, and paroxysmal, or exacerbating. The sharp, 



462 ACUTE PERIMETRITIS. 

stabbing, exacerbating pain is accounted for, as before said, by the 
friction of the two surfaces of the peritoneum, rendered dry and rough 
by the inflammation. In cause and character the pain resembles 
that of the early stages of pleuritis. 

While pain is one of the most constant symptoms, cases do occur 
in which there is very little pain, probably because early effusion, or 
some other condition, prevents the friction. Another consideration, 
which will enable us to account for the absence of pain, is the great 
difference in the susceptibility of different persons. However we 
may explain it, we know from observation that pain is sometimes 
almost entirely absent, and then the disease may be mistaken for 
some other affection. 

In the commencement there is a sharp febrile reaction, with its 
attendant phenomena, as quick pulse, headache, delirium, nervous 
excitement, and derangement of the secretory functions, etc. 

The intensity of the excitement will depend very greatly upon the 
suddenness of the attack and extent of the tissue affected by the in- 
flammation ; greater when sudden and extensive, and less when the 
progress of the inflammation in the first stage is slow and the parts 
involved are small in extent. The febrile reaction is usually high at 
first, and very much moderated as the effusion occurs. 

The character of both pain and febrile reaction are greatly modified 
by the conditions which give rise to suppuration. As suppuration is 
established the sharp pain gives way to a sense of tension, weight, 
and heat, while the febrile movement becomes more remittent or 
paroxysmal. Debility, copious perspiration, and frequent chills make 
up the items indicative of suppuration. 

These symptoms are partially or completely relieved by opening 
the pyogenic cavity and permitting the pus to be discharged. The 
points where the pus flows, as in cellulitis, are the upper part of the 
vagina, rectum, the bladder, inguinal or femoral canal, some place in 
the abdominal wall, the gluteal region, or one of the greater lips of 
the vaginal orifice, and rarely the peritoneal cavity. 

If suppuration does not occur, and the case terminates in convales- 
cence without it, the symptoms gradually subside. 

Upon examining the lower abdominal region we will generally find 
tenderness upon pressure, and often more or less tumefaction, with or 
without tympanitis. The uterus, if displaced, is pressed forward, but 
it often occupies its normal position. In the first stage there is gen- 
erally not much tumefaction in the pelvis felt through the vagina, but 
great tenderness behind and by the sides of the uterus. When the 
fingers are pressed well upward in the stage of effusion there is tume- 
faction behind the uterus, and sometimes in the iliac and hypogastric 
regions. 



LOCAL PERITONITIS. 463 



Diagnosis. 



When free from complications, — which, I must say, judging from 
my own observations, I believe to be less frequent than the converse, 
— I do not see why there should be any great difficulty in differen- 
tiating local peritonitis. The affection with which it is more likely to 
be confounded than any other is cellulitis. The pain in the first stage 
of cellulitis is more steady ; is dull or aching, instead of stabbing or 
lancinating : and the tenderness, although considerable, is not so great 
as in pelvic peritonitis. In the second stage the pain in the two 
affections does not differ much, if at all. The tumefaction is not in 
the same locality ; in cellulitis it is by the side or in front of the 
uterus, while in local peritonitis it is behind that organ. 

If the peritonitis extends above the pelvis, which it often does, it 
may be in one or both iliac cavities, or extend across the lower part 
of the abdomen. When the effusion in peritonitis is above the pelvis 
in the centre percussion will elicit marked resonance, because the in- 
testines are contained in the mass, and this resonance will enable us 
to distinguish it from a tumor. 

The history, symptoms, and physical signs enable us to decide be- 
tween local peritonitis and retrouterine hematocele. In peritonitis 
the history is one of inflammation, well marked in the beginning and 
throughout its whole progress, while that of hematocele does not 
indicate inflammation in the beginning of the attack, and seldom in 
any of its later stages. In local peritonitis metrorrhagia is not a 
symptom ; in hematocele it is. Tenderness is a permanent feature 
in peritonitis, while it is very slight if it is present in hematocele. 
This remark applies when pressure is made above the symphysis or 
in the vagina. The pelvic tumors in both disorders are ordinarily 
retrouterine, and not dissimilar in shape ; but in the earlier periods 
the hematocele is uniformly soft, while the inflammatory effusion is 
harder. The hematocele displaces the uterus more than the inflam- 
matory product. The tumors caused by both may and often do ex- 
tend above the pelvic brim. The bloody tumor is generally central, 
and forms a somewhat level line across the lower abdomen, while the 
inflammatory tumor is usually irregular and hard, and is often con- 
fined to one iliac region. 

In retrouterine pregnancy the absence of acute inflammatory symp- 
toms, unless in exceptional cases, and the presence of the evidences of 
pregnancy, are strong differentiating circumstances, and will generally 
lead to definite conclusions. In extrauterine pregnancy we can watch 
the case for a sufficient length of time, and the growth of the tumor 
will do much to solve the difficulty. 

The pelvic tumors formed by cancer differ from those of local peri- 
tonitis in the facts that they have no inflammatory history, in their 



464 ACUTE PERIMETRITIS. 

great hardness and irregularity of- growth. Fibrous tumors have no 
inflammatory history, are more or less movable, more dense and 
regular in outline. The fibrous tumor is generally accompanied by 
metrorrhagia, while the inflammation is not often attended by that 
symptom. 

Prognosis. 

When peritonitis is confined to the pelvis and its vicinity it is rarely 
fatal. One of the dangers connected with it is the probability of its 
extension to the whole or greater part of the abdominal peritoneum. 
This is much more likely to occur in puerperal cases. The fatal ter- 
mination is sometimes the result of exhaustion induced by protracted 
suppuration and febrile excitement. 

Acute pelvic peritonitis has a strong tendency to become chronic by 
the continuance of the inflammation in a subdued form. In this 
condition, by exposure, over- exertion, sexual excitement, or injudi- 
cious treatment, it may become intensified to an acute degree. When 
pelvic peritonitis has resulted in collections of pus in portions where 
the evacuation of the fluid is imperfect, the inflammation may be 
protracted to an indefinite time. Fortunately, however, in the great 
majority of cases it passes into convalescence, which is usually slow, 
but complete. 

Before giving the treatment of local peritonitis I must again say 
that this disease is so frequently complicated by cellulitis that its 
occurrence in the simple form is not common. I believe, also, that 
simple cellulitis is as rare as uncomplicated local peritonitis. But it 
is very often the case that the cellulitis is comparatively intense, while 
the peritonitis is not severe, when the symptoms and physical signs 
are those of cellulitis ; and again, the peritonitis may assume a grave 
form, while the cellulitis exists in a very moderate degree, when the 
symptoms of peritonitis will predominate. The contiguity of the 
tissue implicated in these two affections, and the identity of vascular 
and nervous supply, are facts that hardly admit of any other conclu- 
sion than that inflammation does not generally invade either of them 
and leave the other unaffected. 

Treatment 'of Perimetritis. 

From what I have seen and had to do with these affections, I am 
led to prescribe in a general way the same treatment for both of them. 

In the early days of an attack of peritonitis the object of treatment 
should be to abort the inflammation, and, when this is impracticable, 
to limit its extent. We can seldom accomplish the first of these objects 
unless we see the patient and recognize the nature of the attack in the 
very beginning. It is not possible to declare just how many hours or 
days must elapse when we are no longer justified in trying to arrest 



TREATMENT OF PERIMETRITIS. 465 

the disease, for this will greatly depend upon the intensity, but we may 
always find something in the conditions to guide us. Before any con- 
siderable amount of effusion and tumefaction has taken place we may 
hope to check the progress of the inflammation, even if this is two or 
three days after the commencement, or, when great swelling has 
occurred, we may still expect to limit its extent. The symptoms indi- 
cating the measures necessary to interrupt the inflammation are great 
pain, accompanied by tumefaction. These call for an energetic anti- 
phlogistic treatment as the strength of the patient will bear. If she is 
robust, from twelve to twenty leeches on the hypogastrium should be 
applied at once, and after they have fallen off the hemorrhage must 
be encouraged by poultices or fomentations until, if possible, the hard- 
ness of the pulse is affected. At the same time a large dose of opium, 
or one of its preparations, should be administered, and repeated in 
such quantities as to keep the pain in complete subjection, and not 
merely given from time to time when the pain returns. 

If the patient is not robust we cannot resort to bloodletting, but 
we must always administer the opium in this way. As secondary 
measures the arterial sedatives may follow the depletion, when that 
is deemed advisable, or be our main reliance if we do not consider it 
best to deplete. Veratrum viride has gained such a reputation that 
it would naturally suggest itself as the most efficient of these. It 
may be given in doses sufficient to control the circulation, and keep it 
under control for the first five or six days of severe attacks. Poul- 
tices or fomentations to the hypogastric region should be one of the 
features of the treatment for the whole of the more active stages of 
the disease. They will often give marked relief. Large injections 
of very warm water, the patient lying on her back, should also be 
employed. An apparatus that will permit the water to run off with- 
out wetting the clothing will be indispensable to the proper manage- 
ment of the injections. This kind of treatment will sometimes check 
the force of the attack in a very short time by arresting or limiting 
the extent of the inflammation, and thus save the patient from the 
protracted suffering which neglect of energetic treatment is sure to 
entail. 

After the effusion has taken place, and before the period of sup- 
puration has arrived, alteratives, such as mercury and iodide of potas- 
sium, are very important remedies. The former may be given in small 
and frequently-repeated doses, until the slightest possible indication 
of its general effects are noticed, when it should be displaced by the 
iodide. This is the period when decided saline laxatives are useful 
and advisable. 

When the symptoms indicate the commencement of suppuration we 
can no longer continue all of the foregoing treatment. 

30 



466 ACUTE PERIMETRITIS. 

The opiates may now be given when the pain requires it. The regi- 
men and medication should be changed to quinine in liberal doses, 
two to four grains or more, as often as necessary, to keep up its influ- 
ence, and supporting food in as large quantities and such quality as 
the stomach and rectum will bear. 

Unfortunately we are often called upon to treat patients who have 
already passed the time when any other than the supporting and 
anodyne treatment would be entirely out of consideration, because 
many of these patients have been too greatly reduced by preceding 
influences to permit of any other than anodyne and supporting treat- 
ment from the beginning. These are the unfortunates who linger for 
weeks, and sometimes for months, in spite of anything we can do for 
them. 

During the progress of perimetritis there is a time when counter- 
irritation will be of great service. After the more acute symptoms 
have subsided, and effusion is evident, a blister applied over the iliac 
region, where the pain is greatest, or over the hypogastrium, if that is 
the location of the most pain, will be required. 

The blister applied at this time will often relieve the deep-seated 
pain, prevent the effusion from becoming purulent, and excite the 
absorbents to remove it. 

Later in the disease tincture of iodine will go far toward accomplish- 
ing the same objects. 

A question arises at the suppurative stage of the affection which 
must be decided after a careful survey of the whole case, viz., should 
we evacuate the pus, or should this process be wholly left to nature ? 
As one of the disastrous terminations is a rupture in the peritoneal 
cavity, as nature often selects very circuitous and unsatisfactory via- 
ducts, as the rectum, bladder, etc., and as a consequence of this last 
circumstance the recovery is very much protracted, I think we should, 
when practicable, furnish the pus an outlet of our own choosing, and 
as early as can be conveniently done. Soon as evidences of suppu- 
ration begin to be manifested through the general symptoms, we 
should make as thorough an examination as we can to ascertain where 
the collection has occurred. If we can discover the pus, we evacuate 
without apprehension of damage to any of the organs. If our first 
examination fails to satisfy us, it should be repeated as often as every 
twenty -four hours until the discovery is made. When this is done, 
we institute one or two precautionary measures, which will almost 
preclude the possibility of doing harm by an intelligent penetration. 
The first is to completely evacuate the contents of the bladder and 
rectum by the catheter and an injection. We ought to be sure that 
the rectum is empty of fluid and gas. I knew fluid in the rectum to 
so far deceive a practitioner as to cause him to make preparation for 



TREATMENT OF PERIMETRITIS. 467 

its puncture. We ought to pass the catheter into the bladder and 
rectum after we sit down to operate. The next precautionary measure 
is to introduce the exploring trocar into the tumor, and after the pus 
has made its appearance, open the cavity by the side of the retained 
canula. In this way I think there is great safety in the operation. 
The patient may be prepared for the puncture by being placed on 
the left side before a good light, as if for operation for vesico-vaginal 
fistula, and anaesthetized. The part may be exposed by Sims's specu- 
lum. The instrument most convenient for making the incision is a 
tenotomy knife. The opening should be free and direct, so as to 
permit of a ready discharge. The opening should not be allowed to 
close. This may be prevented by keeping a tent in the wound until 
the pus ceases to be discharged. The objects of thus opening the 
cavity are to secure an external and safe outlet and its ready evacua- 
tion, and thereby attain a speedy cure and safety against peritoneal 
inflammation. When the chronic form consists in frequent repeti- 
tions of the inflammation, on account, perhaps, of its imperfect sub- 
sidence, much may be done by persistent counter-irritation, and 
among the best kind is a seton in the groin kept running for months. 
An issue will have equal good effect. This permanent form of counter- 
irritation is better, I think, than blistering or pustulation. When the 
opening into the intestine or bladder becomes fistulous, as it some- 
times does, and the discharge continues for months and even years if 
there is no vaginal opening, and the discharge is into the bowel or 
bladder, we should seek for a point in the tumor where it may be 
punctured, and the opening made free and direct through the vagina. 
If no such point can be found, we cannot, with propriety, interfere 
surgically. The openings are, however, often located so that we may 
easily reach them, as through the lower part of the abdominal walls, 
the labia, the gluteal region, the perineum, or vagina. If the orifice 
is accessible, we may generally succeed in obliterating the suppurating 
cavity and fistulous canal. Preparatory to making an effort to do so, 
we should try to ascertain the tortuosities of the fistulous duct and 
the depth of the pus-cavity. In some instances the canal is so crooked 
that the straight probe will pass but a very short distance, and it be- 
comes necessary to send it in various ways ; and sometimes an elastic 
or elm bougie will suit better for a probe than the ordinary metallic 
one, Professor Simpson recommends leaving a wire in the track of 
the fistula until adhesive inflammation is excited. I have not tried 
this means, for I have been so well pleased with injections of car- 
bolized water that I have used them almost exclusively. I inject 
through a small-sized catheter. The smallest-sized elastic catheter, 
pushed to the bottom of the cavity, will convey the fluid in its con- 
centrated strength to the bottom, and thus produce the effect at that 



468 ACUTE PERIMETRITIS. 

point. We ought, after introducing the catheter, to inject the cavity 
with tepid soapsuds, so as completely to cleanse the internal parts of 
pus, and then immediately introduce the solution. 

Sometimes the first injection prevents the production of pus and 
causes adhesive inflammation. In order effectually to inaugurate the 
treatment, it generally becomes necessary to slit up the orifice of the 
fistula somewhat, as it is usually smaller than any other part of the 
duct. 



CHAPTER XXVII. 

CHRONIC PERIMETRITIS. 

Chronic perimetritis is a common form of disease. It is the 
cause of much suffering and is often misunderstood. 

Causes. 

By far the greater number of cases can be traced to the acute form, 
but there is no doubt that many others have an entirely different 
origin. 

Most practitioners of extensive observation must have seen many 
cases of chronic perimetritis, in the history of which no evidence 
could be found that the patient had ever had an acute attack. 

We know that the acute form is often the result of an extension of 
inflammation from the uterus and vagina to the broad ligament and 
peritoneum, and I think I have seen instances where inflammation 
of a moderate grade had been propagated from the uterus and re- 
mained thus associated for an indefinite length of time. 

This I think is the right way to account for those cases so fre- 
quently found complicating chronic uterine diseases, and in which 
the symptoms of perimetritis are completely masked by those attend- 
ing the more prominent affection. 

It is indeed very seldom either in the acute or chronic form that it 
is not accompanied by inflammation of the uterus, and it is equally 
rare that the disease is not propagated from the uterus or vagina. 

In very few cases it is reasonable to suppose that the inflammation 
may originate in the ovaries. 

I do not hesitate to assert, however, that I have not seen mauy cases 
of acute or chronic perimetritis, — where their history could be clearly 
traced, — that were not secondary in their origin and transmitted from 
the uterus. 

Varieties. 

Chronic perimetritis presents quite a variety of appearances ; one 
form traceable directly to the acute attack is chronic abscess. 

After the process of suppuration has led to a discharge of pus, and 
the acute symptoms have subsided, the patient still suffers from ten- 
derness, pain, and long-continued suppuration. The pyogenic cavity 
is perpetuated by the imperfect discharge of pus. While the pus is 
being constantly discharged, the sac whence it comes is not entirely 
emptied, and there is enough pus generated to keep up a perpetual 



470 CHRONIC PERIMETRITIS. 

drain. The manner in which the original opening was effected is 
almost always the cause of this imperfect evacuation of the abscess. 
The canal or conduit leading from the cavity is tortuous, and pene- 
trates the muscular fibres of the rectum or bladder diagonally, so as 
to form a valvular opening. The pus, after having travelled along 
between the different muscular layers of the walls of one of these 
organs, makes an opening that is closed with every contraction and 
opened with each relaxation of the fibres. Still another unfortunate 
method of perforating the intestinal tube or bladder is when the level 
of the sac is below the opening. In all of these ways the complete 
evacuation may be prevented and the discharge protracted for years. 
We meet with another form of perimetritis in which the abscess seems 
to have been cured after complete evacuation. The subsidence of the 
symptoms is so complete as to leave the patient in the enjoyment of 
fair health. After a time, of greater or less duration, sometimes a few 
weeks only, at others several months, the symptoms recur in a less 
severe degree than in the acute form, and after a duration of several 
days or weeks a discharge of pus is again succeeded by relief. 

These attacks are repeated an indefinite number of times, and if the 
patient recovers it is after a number of months or years. 

The suffering is sometimes very great and followed by large dis- 
charges. More frequently, however, the pain is not so excruciating 
and the discharge of pus is small. 

Again, other cases are met with in which the progress of the in- 
flammation from the beginning is very slow, and not attended with 
very severe pain, but continues until quite a large amount of pus is 
formed, which remains in the sac, with very little tendency to ulcerate 
through the tissue. Whether the pus in some of these cases would 
ever be discharged by spontaneous processes is a matter of great un- 
certainty. I have seen cases where from the history I felt assured 
that this indolent abscess had existed for years. 

I saw a case in this city with Dr. T. D. Fitch, that he informed me 
had been in the condition it was when I saw it for three years. That 
he had seen it, discovered pus, and advised its evacuation, as long as 
that, before I was called. I have seen others equally protracted in 
my own practice and in consultation. 

Some cases are met with, the history of which includes a number 
of recurring acute or subacute non-suppurating attacks, weeks or 
months apart, that finally culminate in suppuration. Patients suf- 
fering from this form have an attack of fever, with pain in the pelvis, 
pains running down the limbs, tenderness, and perhaps very slight 
tumefaction of the hypogastric region. This passes for "inflamma- 
tion of the bowels." The patient more or less completely recovers 
from the attack, and after a time is again prostrated with similar but 
less pronounced symptoms, these run a course of four or six weeks 



SYMPTOMS AND DIAGNOSIS. 471 

and the patient again recovers. This time the fever may be called 
typhoid or bilious fever; in a subsequent attack suppuration reveals 
the true character of the disease. The explanation of all these symp- 
toms is that the patient had several attacks of moderate perimetritis, 
that for want of proper physical examination were misunderstood 
and called by different names. 

But all cases do not end in suppuration. The exudate does not 
break down, but continues hard, and is formed in masses of greater or 
less size in the broad ligament, attached to the side of the uterus, or 
between the uterus and bladder. Or where the disease is in the peri- 
toneum the exudation may be above the brim of the pelvis in the iliac 
region. These deposits of fibrin are often mistaken for tumors. Not 
unfrequently a large part of one side of the pelvis is filled with a hard 
immovable mass of plastic effusion, and the uterus misplaced and 
fixed in its malposition. In other instances the accumulation is small 
and does not affect the position or mobility of that organ. 

Instead of the localized effusions here described, sometimes there 
is a diffuse moderate infiltration of fibrin in the cellular tissue that 
causes thickening of the ligament. The parts are less elastic than 
usual, the uterus less movable yet not fixed. 

This condition is the one most frequently present when the uterus 
is said to be "bound down," so that it cannot be reposited and re- 
tained in position without causing great suffering or awaking acute 
inflammation. 

There is also a very moderate degree of chronic inflammation — 
hyperaemia with sensitiveness — which invades and remains in the peri- 
metric tissue without causing effusion or any considerable degree of 
tumefaction. 

Whether this degree or form of disease is one introductory or pre- 
paratory to the more grave acute grade, or one that may last indefi- 
nitely, without any great variation in intensity, is not certain. It is 
probably the condition to which the term — so frequently used — 
"latent inflammation" is applied, because under certain favoring 
circumstances the vascular and nervous action is developed into the 
acute form. 

I have no doubt that this low degree of inflammation may exist a 
long time, and perhaps indefinitely, in the absence of causes exciting 
it to a higher grade of action. 



Symptoms and Diagnosis. 

Generally the symptoms of chronic perimetritis are not distinctive, 
and arrange themselves under the general head of " Uterine Symp- 
toms." In those cases in which pus is formed the symptoms become 
more marked, and we may not be at a loss to understand them ; but 



472 CHRONIC PERIMETRITIS. 

even in some of these the symptoms are not decisive. We must, for 
the most part, therefore, depend upon physical examination. The 
history of those cases of frequently recurring paroxysms of pelvic 
inflammation, which for many months, or even years, precede sup- 
puration, will often indicate pretty clearly the character of the disease 
with which we have to deal. Yet, without an examination of the 
pelvic organs, even these cannot be diagnosed until they have about 
run their course. 

There is generally one element which, to one whose attention is 
attracted in that direction, will be found to be almost always present, 
viz., fever in a more or less marked degree. In all but the indolent 
abscess, and the slighter degree of its form, in which there is no exu- 
dation, this symptom will pretty uniformly present itself. 

Physical examination will uniformly develop sensitiveness. It will 
often happen that, during the examination, the tenderness will be so 
slight as not to elicit complaint from the patient ; but, after the mani- 
pulation is ended, there will be left aching and a sense of tenderness. 
Sometimes the reaction will be quite severe and last for hours, or even 
awaken an acute attack. This subsequent tenderness, however slight, 
is a symptom of much significance, and should teach caution in future 
examinations. 

Another important sign (yet not so important as the last) is certain 
positions of the uterus. When the cervix is drawn strongly to one 
side, and especially if it is fixed in that position, it indicates an 
irregularity in the length of the broad ligament. The ligament of the 
side toward which the traction is noticed is shortened, and, while not 
invariably so, the shortening is frequently owing to previous or present 
inflammation in the connective tissue of the ligament. If associated 
with tenderness this condition ought to complete the diagnosis. 

Bimanual examination of the sides of the pelvis will generally 
enable us to detect even a small amount of fibrinous deposits. They 
may generally be diagnosed from tumors by their tenderness, fixed- 
ness, and locality. In most cases they will be fixed to the pelvic 
walls, especially when situated, as most of them are, in the connective 
tissue of the broad ligament. Sometimes, however, they are developed 
at the side of the uterus, and adhere firmly to it. In such cases they 
move with the uterus, and cannot be made to move upon that organ. 
These are more likely to be mistaken for subserous fibrous tumors. 
The history will do something toward clearing up the diagnosis. There 
will always be a history of inflammation. The menses are not so likely 
to be profuse as in the case of fibrous tumors. Each manipulation 
will be attended or succeeded by tenderness. When the deposit is 
extensive the position of the uterus is generally affected by it also. 
The indurated patches at the brim of the pelvis, left by local perito- 
nitis, are sometimes mistaken for tumors. We should give due weight 



TREATMENT. 473 

to the history of inflammation, with which these are connected, and 
the tenderness that is developed by pressure and other manipulations. 
When examining them we will generally find them flat instead of 
globular, and not movable. But the most remarkable, and, I think, 
pathognomonic sign, is resonance under percussion. However exten- 
sive these indurated masses may be, percussion will elicit intestinal 
resonance over the whole space occupied by them. The resonance is 
due to the fact that the effused fibrin surrounds, instead of displaces, 
the intestine, and in coagulating includes that tube in the indurated 
mass. These signs are all. different from those evinced by an exami- 
nation of a tumor. The signs of the indolent abscess of the broad 
ligament are an immovable tumor, which is elastic or fluctuating, 
and the test is aspiration. 

Treatment. 

The treatment of these several diverse conditions must necessarily 
vary. The form in which sensitiveness and hyperemia are not 
attended with effusion will require great circumspection in the treat- 
ment. 

One is continually tempted by local inconvenience to depend too 
much upon stimulating local treatment, whereas I think it is benefited 
less by local measures than any other form of the disease. It is, in 
fact, more frequently connected with, if not dependent upon, some 
dyscrasia (or dysthetica) than upon local conditions, and hence must 
be treated largely by general measures. One of the most efficacious 
of these measures is a judicious change of climate and habits. The 
object in making a change of climate and habits should be to revolu- 
tionize the circumstances of the patient. It is astonishing how these 
patients, who cannot stand upon their feet, on account of the great 
sensitiveness of the pelvic organs, will improve on a long journey, 
which, from the symptoms, would seem impracticable. A trip to, and 
residence in, California has done more to cure some of these patients 
than could have been done by medicine alone. But much good can 
be done by medicines, such as will improve the condition of the sys- 
tem. The boAvels should be the subject of special care. They will 
more frequently than otherwise be constipated, and their secretions 
inferior in quality as well as scarce in quantity. The mercurials and 
bitter tonics, if perseveringly administered, will often correct the con- 
stipation, improve digestion, and act favorably on the depraved state 
of the general system. 

The sixteenth of a grain of the bichloride of mercury, with a full 
dose of the compound tincture of cinchona, or the tincture of Colombo, 
three times a day, makes an excellent mixture for such cases. The 
diet should be full in quantity and nourishing in quality. Exposure 
to the fresh air and sunshine is also indispensable to restoration. The 



474 CHRONIC PERIMETRITIS. 

exercise should not be too much restricted, because confinement 
always aggravates the general condition, and moderate exercise is not 
harmful to the local trouble. The special treatment should consist 
in large injections of tepid water, and extensive but very moderate 
counter-irritation. 

The counter-irritant I rely upon most is the tincture of iodine," 
diluted with an equal quantity of alcohol. This liniment should be 
applied over the whole lower part of the abdomen, back, and hips. I 
believe, however, that the local treatment can often be dispensed with 
if judicious management of the general health is persevered in and 
diligently applied. 

In the cases in which fibrinous deposits are observed, special treat- 
ment is of more importance. And the first thing that I would insist 
upon is that pessaries and stimulating applications to the uterus should 
be abjured. 

Large hot or tepid water injections and sitz-baths will be of great 
service. It will sometimes be found that hot- water injections will 
cause discomfort, while tepid water will be followed by relief, and the 
effect experienced from them should guide us in our choice. 

Concentrated counter-irritants in the inguinal regions will also be 
found very beneficial. A small seton I believe to be the best form of 
counter-irritant, and when kept clean and shielded from the friction 
of the clothing it will give the patient but little inconvenience. We 
must not forget the soothing influence of glycerin tampons. 

Diligent attention to the general health is of the greatest importance 
also, and very small doses of mercury, laxative diet, and exposure to 
pure air in a mild climate will generally suffice. In the suppurative 
variety, which is but the advanced stage of the latter form, attention 
to the general health is of paramount importance. When the suppu- 
ration is intermitted with intervals of comparative comfort, we may 
generally interrupt the paroxysm by establishing and keeping up for 
a considerable period a discharge from the iliac or inguinal region 
over the seat whence the discharge emanates. I know of no one remedy 
that does so much good as the seton. It should be larger than in the 
last variety, and the local irritation kept up for several weeks or even 
months. 

When the suppuration is continuous, in addition to attending to the 
general health, we should try to establish a more direct outlet. When 
the discharge is from the rectum we may sometimes pass a bent probe 
through the opening and bring its point down upon the roof or side 
of the vagina, and make it a guide to a puncture in that direction. 
When we cannot improve the direction of the outlet we may sometimes 
destroy the pyogenic character of the cavity by injections of carbo- 
lized water through a flexible catheter, introduced and carried to the 
bottom of the cavity. 



TREATMENT. 475 

How to treat chronic pelvic abscess in all its phases is one of the 
most difficult problems in gynecological surgery. The plain proposi- 
tion to evacuate the pus and maintain a free opening expresses the 
main objects to be accomplished. The difficulty consists in selecting 
the best method of doing so in all cases. Of course this will vary with 
the differences noticed in each case. A rule which is, I think, a good 
guide, is to open the abscess through the nearest surface. If nearest to 
the vagina it should be opened into that cavity, if near the rectum, 
into the rectum. Sometimes the pus makes its way to the cutaneous 
surface and then it must be evacuated at the point it approaches. We 
will seldom be able to divert the pus from the course it takes in making 
its way out. When practicable the opening should be at the lowest pus 
level and when we can choose the most favorable time and locality for 
the evacuation, the results will be satisfactory, both as to the primary 
and continued evacuation. 

Perplexities are now frequently met with when the abscess has dis- 
charged spontaneously in some unsuitable place and in such a manner 
as to prevent a complete discharge. In cases where suppuration takes 
place near the vagina, and the pus finds its way into that cavity it 
is generally easy to correct any defective manner in the discharge 
by enlarging and keeping the opening patent until the cavity is ob- 
literated. 

If there is any difficulty in rinding the opening, or in the manipula- 
tion for its enlargement, the vagina may be stretched and dilated suf- 
ficiently to give freedom in our operations. This will often greatly 
facilitate our efforts and thus insure the best results. For this purpose 
we may use Sims's or Simon's speculum, or we may employ our thumbs 
as for dilating the rectum. The enlargement of the opening to the 
abscess should be effected by stretching and tearing rather than cut- 
ting. Thus we will risk but little from hemorrhage. The dilatation 
can be done by a small bladed uterine dilator and the finger, or by 
Hanks' rubber dilator succeeded by the ringer. After thus dilating 
the opening the whole interior of the cavity should be scraped by the 
ringer or dull wire curette, for it will generally be found that the inner 
surface of the chronic suppurating cavity is covered with large, irregu- 
lar and indolent granulations. These should be thoroughly removed. 
The cavity ought be washed out daily with plenty of pure warm water.. 
Sometimes there is a tendency in the discharging orifice to contract 
and close up. This may be counteracted by repeating the dilatations 
with the finger as often as necessary. 

If the suppurating cavity has discharged into the rectum,, and the 
evacuation is unsatisfactory, and draws out a tedious and chronic 
course, the treatment should be the same as directed for the vagina. 
The rectum must be dilated by the thumbs to the greatest extent. 
When this is sufficiently done the whole rectal cavity maybe brought 



476 CHRONIC PERIMETRITIS. 

within reach and view by retractors and we can with great facility and 
safety operate within it. I have on more than one occasion reached 
the discharging orifice of an abscess at the brim of the pelvis. After 
the exposure of the discharging orifice the treatment is the same as in 
the vagina. 

In speaking of my treatment of abscess of the pelvis some of my 
friends have misunderstood and misinterpreted me. I have been 
understood as advising the use of cutting instruments in enlarging the 
opening. I mention this with a view to correct this impression. I have 
thus far only attempted the enlargement of the inadequate opening 
already existing with instruments that would not cut, and as much as 
possible with the finger. This plan has been objected to through fear 
of hemorrhage ; but following the directions here given there is no 
more danger than operating through the vagina. And it will be ap- 
parent to any one doing this operation that if a vessel were wounded 
the ligation of it would be not at all difficult. 

The cavities of most chronic abscesses of the pelvis are not simple 
and uniform in shape, but often present subdivisions with partitions 
and projections from their surfaces, more or less completely dividing 
them into compartments. These should be broken down by the 
finger in order to permit the free flow of pus from every part. Some- 
times the level of the pus-cavity is lower than the orifice through 
which it escapes. In that case the elevated septum between the rec- 
tum and the suppurating cavity should be torn down by the finger to 
a level with the bottom of the purulent cavity. Again I can assure 
the reader that when this is carefully done there is no danger from 
bleeding and that any severed vessels may be secured without diffi- 
culty. 

The important points in this method of evacuating the pus from a 
pelvic abscess through the rectum are : First, to stretch the sphincter 
until the whole interior of the rectum is brought to light. Second, to 
tear the old opening of the abscess so largely as to admit the easy in- 
troduction of the fingers. Third, to reduce the irregularities of the 
cavity by tearing them away. Fourth, to reduce the septum dividing 
the abscess from the rectum to a level with the bottom of the pyogenic 
cavity. Fifth, to scrape away by means of the finger or dull curette 
the granular projection from the wall of the cavity. 

As in the case of the evacuation from the vagina, the rectum may 
require dilating again, as it will also be necessary sometimes to repeat 
the stretching of the opening to the pus-cavity. 

There are undoubtedly instances very high up — partly abdominal 
— from which the pus cannot be evacuated according to the plan I 
have directed. In these laparotomy is advisable, in fact, demanded, 
as the only method of reaching the cavity. I am sure, however, such 



TEEATMENT. 477 

cases are rare. Mr. Tait, if I understand him rightly, and others, 
prefer laparotomy and drainage above the pelvis to the operation 
through the rectum. I have not done laparotomy for pelvic abscess 
except where connected with the tubes, but I have had the oppor- 
tunity of seeing the results of four cases, and have witnessed two oper- 
ations. I was strongly impressed with the difficulties and dangers of 
this very formidable procedure as compared to those of the operation 
through the rectum. 

In laparotomy for pelvic abscess the incision should be low down 
in the median line, or what in some cases is better, over the upper 
part of the abscess, near the line of the pelvis or Poupart's ligament if 
on the sides. When the abscess is exposed the edges of the incision 
should be stitched upon it, so that there may be room enough for the 
evacuation between them without danger of the pus finding its way 
into the peritoneal cavity. When the opening is made through which 
the pus escapes, the peritoneal cavity may be thoroughly washed out 
and a drainage-tube inserted. The wound may then be dressed anti- 
septically and treated as wounds in the abdominal walls for other pur- 
poses. 

The difference as to the dangers and difficulties of performance 
between laparotomy and the operation through the rectum are so 
great that I cannot recommend the former except as a last resort, and 
after the latter operation has failed. 

We occasionally meet with a collection of pus at the superior strait 
extending into the pelvis and sometimes attaining very imperfect 
evacuation through the rectum. This may be incised and evacuated 
without opening the peritoneal cavity, and drained with very little 
danger. 

Before leaving the subject I will mention another objection urged 
against the operation of enlarging the opening of an abscess through 
the rectum, viz., the danger of the faeces making their way into the 
cavity and producing irritation. This objection will not be seriously 
entertained when it is remembered that the sphincter is rendered pow- 
erless to retain the contents of the rectum and that the abscess-cavity is 
so shaped by the operation that the faeces would not be retained. Then 
it should be further remembered that healthy faeces are not irritating to 
the inside of these cavities, and that the cavity is to be thoroughly 
washed out once or oftener every day. Another thing about which I 
wish to be a little more explicit is that of the opening of an abscess 
in the rectum. From considerable observation I am convinced that 
there is no more danger in opening an abscess through the rectum 
than through the vagina. The way I have lately operated is, after 
stretching the rectum so as to see and feel the place where the pus is 
located, to insert the point of a scissors with the blades closed and 



478 CHRONIC PERIMETRITIS. 

follow with the point of Hanks' rubber dilator. The dilator may be 
made to cause quite an opening, but this may be enlarged by the 
finger or other instrument. There will be no hemorrhage if the opera- 
tion is done without cutting. 

In the case of the indolent abscess all that will generally be found 
necessary is to draw off the pus by the aspirator. In this variety the 
lining-membrane (or wall) of the cavity has ceased to produce pus, 
and consequently when the sac is emptied the fluid does not reaccu- 
mulate. I have seen several cases thus happily terminated. 



CHAPTER XXVIII. 

DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. 

In every displacement of the uterus the direction of the axis and 
the calibre of different parts, or the whole of the vaginal canal, are 
changed from their normal conditions. In procidentia the vagina is 
in part or wholly inverted. In such cases, however, the changes are 
complications of the displacements of the uterus, and are described 
and treated as such. 

The more common and yet not entirely independent displacements 
of the vagina are known as cystocele and rectocele. 

Urethrocele, Cystocele. 

Cystocele is a prolapse of the anterior wall of the vagina, the latter 
being borne down by a prolapsed bladder, or drawing down that 
organ with it. The prolapses of the anterior vaginal wall and bladder 
may also make sufficient traction upon the uterus to cause prolapse 
of that viscus, and thus be complicated by it without the posterior 
wall of the vagina being much disturbed. Sometimes the mucous 
membrane of the anterior or posterior wall of the vagina may prolapse 
through the vulva without displacing the fibrous sheath, the bladder, 
or the rectum. At other times the urethra alone will descend with 
the vaginal wall. 

Rectocele. 

When the posterior wall of the vagina protrudes externally it is 
generally, in nullipars, attended with displacement of the anterior wall 
of the rectum, and sometimes the uterus is drawn down and displaced 
by traction of the wall of the vagina. In nullipars the rectum is 
usually but slightly displaced. 

Symptoms. 

The symptoms of cystocele are dragging sensation or weight in the 
vagina, with leucorrhcea and burning pain, occasioned by the inflam- 
mation from the exposure or friction of the mucous membrane of the 
vagina, and vesical suffering. In recent cases there is simply frequent 
desire to micturate and unsatisfactory discharge of the urine. 

As the case becomes chronic the incomplete discharge of urine leads 
to its decomposition, the precipitation of the salts contained in it, and 
the evolution of ammonia. 



480 DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. 

The ammonia and salts irritate the mucous membrane of the blad- 
der to a greater or less degree, and in aggravated cases severe inflam- 
mation and ulceration occur, attended with discharge of mucus, blood, 
and fetid gases. 

These local results are attended by constitutional disturbances com- 
mensurate with their gravity. 

The sufferings in rectocele are usually less severe. There is weight, 
leucorrhcea, and unsatisfactory defecation. The muscular coat of the 
rectum loses its tone and permits the fasces to collect in a large mass 
in it, which intrudes into and fills up the vagina. 

When an effort is made to exjDel the excrement it is apt to collect 
in larger quantities and remains in this passive pouch until the 
patient presses or scoojds it out with her fingers. 

Diagnosis. 

Upon examining the vagina the anterior or posterior prolapse will 
be readily discovered, and may be isolated by passing the finger into 
the vagina. If the anterior wall is prolapsed the finger will pass be- 
hind the tumor, and in front of the tumor if the posterior wall is the 
portion affected. 

We may demonstrate a cystocele by introducing the catheter. The 
instrument, instead of passing backward and upward, will go down- 
ward and backward, and the point may be felt occupying the tumor. 
In rectocele, if we introduce the finger into the rectum, it may be 
turned forward toward the vagina and made to enter the tumor. If 
the prolapse consists of the mucous membrane alone, the finger or 
catheter will not pass into the turn or. (See Palpation of the Pubo- 
vesico-uterine Lig., p. 86, also Palpation of Vagina, p. 88, Chapter II.) 

Causes. 

Loss of substance or tone in the perineum is one of the most im- 
portant conditions necessary to prolapse of the vagina. (See Chapter 
VII.) There may be loss of substance in the anterior border of that 
body from rupture, or loss of firmness from subinvolution, lack of 
general muscular vigor, — debility, — or senile atrophy. 

In old women we not infrequently find all the genital organs in a 
state of abnormal relaxation from loss of fibrous tissue. 

Instead of normal atrophy, in which the parts are condensed, as 
the fibrous tissue disappears, there is no contraction, and the uterus, 
vagina, and perineum are reduced to their membranous structures, 
incapable of resisting force in any form. Subinvolution of the vagina, 
bladder, and rectum, on account of the vascularity and laxity attend- 
ant upon that condition, permit displacements, which are favored by 
the weight of these and other pelvic organs. 



RECTOCELE. 481 

Retention of the urine and faeces are also important factors in the 
displacements. They distend and weaken the walls of the viscera 
until they become incapable of resisting the pressure. 

Treatment. 

The same general principles govern the treatment of these two 
conditions. 

If the perineum be deficient, its integrity should be restored by 
perineorrhaphy, and this will often be sufficient to effect a cure of 
either or both. 

When there is no loss of perineum, or the deficiency is slight, we 
may often cure cystocele by returning and retaining the prolapsed 
portion in position until the redundancy of tissue is reduced by the 
contraction and condensation which take place when the distending 
forces are removed or counteracted. 

The instrument which I have found most serviceable in cystocele is 
Zwank's pessary. (Fig. 242). The points upon which it rests are the 
rami of the ischium, and it presents the flat surface of its expanded 
wings upward, affording an admirable lodging-place for the redundant 
tissue. The application of this instrument is not difficult, and when 
of the right size it very generally relieves the symptoms at once, 
especially the irritableness of the bladder. It will be necessary for 
the patient to wear the pessary for many months until the condensa- 
tion or involution is complete. Like every other pessary, this one 
should be removed and examined often enough to insure cleanliness 
and prevent damage to the vagina. 

If it causes ulceration it must be removed at once. Sometimes a 
ring, kept in position by external support, may be made to retain the 
procident wall quite securely. The practitioner should rely upon 
the pessary in most instances of this kind as far preferable to other 
surgical means, except the restoration of the perineum when deficient. 

When a surgical operation is required, the object to be attained by 
it is to remove a portion of the redundant mucous membrane over 
the central part and draw the edges together, and thus lessen the 
calibre of the vagina. 

To the inexperienced this operation seems a formidable one, but it 
is not so, and when attempted the difficulties will rapidly vanish. 
In the natural condition, the mucous membrane of the vagina is 
attached to the fibrous sheath by very loose connective tissue. In 
cystocele the space is much greater, hence, with a tenaculum we can 
lift the membrane freely away from the vaginal sheath and with the 
scissors remove it to any extent we desire. 

As before remarked, the protrusion in many instances is made up 

of the mucous membrane alone, when the operation is easy and a 

complete success. 

31 



482 DISPLACEMENTS OF THE VAGINA, BLADDER, AXD EECTUM. 

When the fibrous wall of the vesieo-vaginal space yields, and is 
prolapsed with the mucous membrane, the operation is much more 
likely to fail, and we will at last be obliged to resort to a support. 

Marshall Hall was the first to remove pieces of the anterior vaginal 
wall, but he limited his amputations to the protruding folds. J. Ma- 
rion Sims denuded an oval surface extending back nearly to the os 
uteri and closed by transverse superficial sutures. Stoltz removes a 
circular piece of mucous membrane and draws it together by a silk 
thread passed completely around the circle in and out of the mucous 
membrane, about an eighth of an inch from the edge. 

"When the urethral fossae and anterior vaginal sulci are loosened from 
their facial attachments behind the pubes, and sag down along with 

Fig. 220. 





Stoltz's Denudation for Cy^cocele (Munde). 



the central ridge. I prefer to remove two small oval strips in the ure- 
thral fossae extending back along the sulci (Fig. 234 . The tissue 
in the fossa? should be removed deep enough to get to the firmer 
fascia so that the edges of the denudation will be held up by it. The 
denudation may. in case the whole vaginal septum be relaxed, be 
made to extend backward along the sulci and be joined under the 
neck of the bladder by a transverse strip, as in Fig. 235. 

In this way the anterior vaginal walls are drawn up into the sulci, 
or to the vesico-vaginal septum, and as nearly as possible reattached 
behind the pubes by deep stitches. Care must be taken that the 
strips be not too wide or the traction upon the stitches will be too 
great. (For particulars as to these operations, see Operations upon 
the anterior vaginal wall for Prolapse and Procidentia, p. 501). 



EECTOCELE. 483 

Judging from my own observation, I should say that rectocele is 
hardly curable in any other way than by operation. The perineum 
is almost, if not always, deficient, which requires an operation for its 
restoration. When this is the case, the two may be cured by the same 
operation. (Chapter VII.) 

Dr. Gillette, of New York, performs an operation for condensing the 
mucous membrane without removing it, by passing silk ligatures 
between the membrane and the fibrous sheath and drawing it up over 
the most protuberant portion. 

The after-treatment is of great importance. The patient should be 
kept quiet in bed and have opium enough to relieve pain, and in cys- 
tocele the urine should be evacuated by the catheter often enough to 
prevent distension. In rectocele the rectal tube must be used to pre- 
vent the accumulation of gas, and the bowels moved by saline laxatives 
every other day. Salines should be used because they liquefy the 
stools. 



CHAPTEE XXIX. 

DISPLACEMENTS OF THE UTEKUS. 

The uterus is normally located at or near trie centre of the pelvis, 
extending from the pelvic brim or slightly below it, to within an inch 
of the coccyx. Its long axis changes its direction or inclination with 
the filling or emptying of the bladder and rectum, with the different 
positions of the body, and with the variations in abdominal pressure. 
In the standing posture the relatively increased direct abdominal 
pressure, and its own weight, carries the fundus downward over the 
bladder; in the dorsal decubitus the relatively increased backward 
or reflected pressure, and its weight, carries it slightly backward. In 
recumbent postures, however, the abdominal pressure has but a feeble 
effect upon the position of the uterus and allows it to move freely 
among the viscera. The action of its supports is then paramount, 
and is sufficient to restore and keep its axis in close relationship with 
the axis of the superior strait. 

An abnormal location of the entire organ, independent of any alter- 
ation of its shape or the direction of its axis, constitutes a dislocation 
or simple displacement; an abnormal position or direction of its axis, 
is called a version ; an abnormal curve of its axis, or the relation of its 
parts, is called a flexion. 

Simple displacements may take place in any direction, and may be 
called forward displacements, or ante-location; backward displace- 
ments, or retro-location ; right or left lateral displacements, dextro- 
and sinistro-locations ; upward, or elevation; and downward, in the 
direction of the axis of the superior strait, constituting descent, or 
lapsus. Descent of the uterine axis on the curve of the pelvic axis is 
called prolapse, and if beyond the pelvic outlet, protrusion or proci- 
dentia. (See Fig. 221). The inverted vagina, the rectum, the bladder, 
the small intestines, one or all, may also come outside of the pelvis 
with the protruded uterus. 

In cases occurring in childbearing women, the bladder, or rectum, 
or both, may precede the uterus, and often act partly as a cause of the 
prolapse, by pulling the uterus down to or through the injured or 
lacerated pelvic outlet. In nullipara the uterus and inverted vagina 
protrude first and may or may not drag the rectum and bladder after 
them. 

Versions are forward, anteversions ; backward, retroversions; right 



DISPLACEMENTS OF THE UTERUS. 



485 



or left, dextro- and sinistro-version, according as the fundus turns in 
any of the directions mentioned. The altered position of the fundus 
is accompanied by a turning of the lower end of the cervix in the op- 
posite direction, upon the cervical attachments as an axis. 

Flexions have the same nomenclature as the versions, and are forward, 
backward, or lateral, according as the concavity is formed by an 
anterior, posterior or lateral uterine wall. 

Two or all of these three varieties of deviations may occur in the 
same case, for instance, anteflexion, retroversion and retrolocation 
(Fig. 225). 

Fig. 221. 




Pathological Changes in Location of the Uterus. Dislocations, The dotted lines show the 

normal position. 

In some cases it is better for the sake of accuracy to mention the 
parts dislocated. For example, in case of anteflexion we may have 
merely a forward displacement of the fundus, or of both fundus and 
lower end of cervix, or we may have a backward displacement of the 
upper end of cervix, or of the corpus with a normal location or for- 
ward inclination of the fundus alone, or lower end of cervix alone or 
of both. We may have a displacement of the cervix to the left with 
fundus in a normal location; or a displacement of the fundus to the 
right with the cervix in the normal position, yet either would be called 
a right lateral version (dextro-version). 



486 DISPLACEMENTS OF THE UTERUS. 

Vliat Constitutes a Displacement of the Uterus. 

The normal variations in location and position of the whole or a 
part of the organ have been termed, by some, physiological displace- 
ments. Thus when the bladder is empty the fundus is pressed over 
the bladder causing the uterus to bend at or near the internal os; when 
the bladder is full the fundus is pressed up so as to straighten the 
organ; the flexion thus produced is called a physiological flexion. 
The same may be said of a flexion of the cervix forward during ful- 
ness of the rectum. Such displacements, or, more properly speaking, 
changes of accommodation in the parts, or the whole, of the uterus do 
not interfere with its normal motions or functions. 

A pathological displacement of the uterus is more or less permanent 
and interferes with its normal motion and healthy functions. For 
instance, Fig. 1 represents a normal position of the uterus when 
the bladder is empty, or nearly so. If, however, the uterus remain in 
this position during filling of the bladder and the fundus cannot, ex- 
cept by force and discomfort to the patient, be raised or pushed back- 
ward, the organ is anteverted. Or there may be a greater bend in the 
uterus than shown in Fig. 1, without constituting a pathological 
anteflexion, but when the axis cannot be straightened by the filling 
bladder or variations in abdominal pressure, or when it interferes 
with functions, it is pathological. Sometimes, however, the fundus 
may be found turned into the hollow of the sacrum at one examina- 
tion ; at another it may be found lying low on the bladder. In such 
cases the normal motions are interfered with on account of the in- 
ability of the supports to promptly return it and hold it in the centre 
of the pelvis, and we observe anteversion and retroversion alternatelv. 



of Uterine Displacements. 

Elevation is caused by tumors intimately or remotely connected 
with the uterus growing up out of the pelvis and dragging the uterus 
up with them, by inflammatory or other contraction of tissues at the 
pelvic brim, by the pressure of pelvic tumor or abscess below or beside 
the uterus, or by a loss of substance, or imperfect development. In 
the latter case the lightness of the organ, and the comparatively small 
surface presented to abdominal pressure above, give the uterine sup- 
ports greater elevating power. 

Of Descent or Lapse. 

Descent or lapse is brought about by symmetrical enlargement of 
the uterus— as pregnancy or other forms of congestion, hypertrophy, 
hyperplasia, subinvolution, small uterine tumors, etc., or by a general 
relaxation of the pelvic supports resulting from parturition, extreme 
emaciation or debility, overwork, prolonged lactation, tuberculosis, 



OF VEESIONS. 487 

etc. Haste in getting up after abortion and labor at term affords one 
of the most common causes, and acts in both of the ways mentioned. 

Of Prolapse and Procidentia. 

Prolapse and procidentia are produced by the same causes as the 
last, but acting in a greater degree upon the sacro-uterine ligaments. 
Relaxation of these posterior supports and the contiguous connective 
tissue from tumors, fecal impaction of the upper rectum, or from 
rectal or peri-rectal disease, and the like (with but little change 
anteriorly), may cause simple prolapse, or descent of the uterus along 
the pelvic axis toward the perineal body. In procidentia the support- 
ing structures of the uterus are all relaxed, but the sacro-uterine to the 
greatest degree. Perineal lacerations and the accompanying drag of 
congested or hyperplastic vaginal and vulval tissues may also have 
much to do in the etiology of both of these displacements, but espe- 
cially the latter. Labor is the most frequent originator of this condi- 
tion. 

Of Displacements Forward, Backward, Sideways. 

Forward, backward and lateral dislocations are seldom the result of 
a heavy uterus or of a weakened system of supports, but rather of 
traction or shrinkage of tissue in the pelvis, or of pressure from patho- 
logical growths. Hematocele and contraction in the pubo-uterine 
peritoneum or connective tissue are the common causes of forward 
displacement, or ante-location. Posterior displacements are ordinarily 
due to contraction of peritoneal inflammatory deposits over or beside 
the sacro-uterine folds or rectum, to relaxation of the vesico-uterine 
ligaments from an over-distended bladder or habitual physical exer- 
cise in stooping or leaning postures. Tumors or inflammatory de- 
posits often press the uterus back. The lateral displacements result 
from the pressure of tumors, abscesses, or inflammatory masses, or 
from relaxations or contractions in the broad ligaments. 

Of Versions. 

Versions are caused chiefly by asymmetrical enlargements of the 
uterus, by tumors or deposits pressing or drawing the fundus or cer- 
vix out of place, or by misdirected or excessive abdominal pressure 
due to deformities, tight lacing, sedentary occupations, etc. In the 
majority of cases the cervix is drawn by a contraction in the tissues 
about it so that the abdominal pressure is brought to bear more 
directly against one of the walls of the uterus. Thus a contraction in 
the sacro-uterine ligaments draws up the lower end of the uterus so 
that the posterior wall is presented to the abdominal pressure, and the 
fundus or movable end is borne down over the bladder, while the ex- 
ternal os is turned backward toward the sacrum (Fig. 53). Contrac- 



488 



DISPLACEMENTS OF THE UTERUS. 



tion in the vesicovaginal septum pulls the cervix forward so that 
when the bladder fills or the patient lies on her back the abdominal 
pressure bears upon the anterior uterine wall and turns it into the 
hollow of the sacrum, and the os forward behind the pubes. Figs. 46, 
47, and 56 represent retroversion in different degrees. Illustrations 
which represent the uterus as passing from anteversion to retroversion 
or from one degree to another of the same version upon the external 
os as a pivot are incorrect, for the pivot is not only near the internal 
os, but the pivot itself usually moves backward in anteversion and for- 
ward in retroversion. (Figs. 229 and 230.) 

Lateral versions take place according to the same principles. 

Contraction of the round ligaments, or peritoneum about them, may 
cause an anteversion without much change in the position of the inter- 
nal os. Fig. 50 represents this somewhat rare form; compare with 
Fig. 53. 

Fig. 222. 




Pathological Anteflexion causeu by a Shortening of the Sacro-uterine Ligaments. After B. S. 

Schultze. 



One of the common varieties of retroversion is combined with slight 
lateral version, and is produced by a puerperal or non-puerperal 
relaxation of all the pelvic supports except at a limited area of atro- 
phic or cicatricial contraction at one side of the cervix. This contrac- 
tion holds up the cervix from the pelvic floor, but hinders the normal 
forward inclination of the corpus and backward inclination of the cer- 



OF FLEXIONS. 



489 



vix ; as a consequence the fundus is forced back until it finds rest upon 
the rectum or between the sacro-uterine folds or in one of the lateral 
sacral pouches. In such position the fundus finds support and the 
tender ligaments rest, and the uterus thus often lies in greater comfort 
than when replaced. Whenever absorption of such deposits and ad- 
hesions takes place and relaxation occurs over the area of previous 
contraction, the last support of the uterus is gone and it becomes pro- 
lapsed or protruded. 

Another important factor in the causation of versions are injuries of 
the pelvic floor and perineum, or inefficiency of the same structures 
from atony or debility. They act less directly than in cases of pro- 
lapse and procidentia, but often with none the less effect. 

Of Flexions. 

Flexions may be caused by the same influences already given for 
version, but the resistance at the cervical attachments causes the uterus 



Fig. 223. 




Anteflexion produced by Contraction in or about the Round Ligaments. 

to bend instead of turning on the cervical pivot, i. e., a hard uterus 
will twist the cervical attachments and turn over, a flabby uterus will 
bend. The healthy uterus will bend slightly, and then slightly twist 
the cervical attachments in its normal range of motion. When the 
bladder is empty the fundus leans over the bladder partly at the ex- 



490 



DISPLACEMENTS OF THE UTERUS. 



pense of a flexure of the uterine body and partly by a slight twisting 
of the lower portion of the broad ligaments. When the bladder fills 
the uterus is strengthened and the lower portion of the broad ligament 
untwisted and slightly twisted in the opposite direction. Such flexion 
and version are normal. 

But when the uterus is drawn back or the fundus held down, so 
that the natural forces, such as the filling of the bladder and dorsal 
decubitus, cannot straighten it, then the flexion becomes pathological, 
and, sooner or later, the organ becomes disordered in function or inter- 
feres with functions of other organs. After a time the concave side 
becomes atrophied or intractile, and the flexion permanent. Fig. 222 
represents an extreme degree of anteflexion due to contraction of the 
sacro-uterine folds. Flexion caused by contraction about the round 
ligaments is usually situated more in the cervix, as in Fig. 223. 

The pressure of the posterior vaginal wall and contents of the rec- 
tum against the lower end of the cervix in the latter case bends it for- 



FiG. 224. 




Puerile Anteflexion. After B. S. Schultze. 



ward, and thus keeps it from being turned back toward the sacrum, 
as, for example, Fig. 222. 

When the posterior vaginal wall is short, and the sacro-uterine and 
round ligaments both rigidly contracted, or naturally short, in early 



OF FLEXIONS. 



491 



life, the external os and fundus may be both turned forward until the 
cervix and corpus lie parallel to each other, both pointing forward 
toward the pubes or pelvic outlet, as in Fig. 224. 

After the causative influences have ceased working, or after the liga- 
ments, by removal of the contracting deposits, or by the development 
of puberty or married life, have been relaxed or elongated, the flexure 
(On account of atrophy or intractility of the concave side) may remain, 
and the fundus, or whole uterus, sink toward the coccyx, and a retro- 
location or retroversion be found along with the anteflexion, as repre- 
sented in Fig. 225. 

When the fundus becomes pushed or pulled back of the pelvic 
axis, abdominal pressure helps to force the fundus back in the recto- 



FlG. 225. 




Anteflexion with Retroversion and Retrolocation. 

uterine or sacral peritoneal pouches, while the traction of the sacro- 
uterine ligaments tends to draw back the cervix to its normal position 
and thus flex the uterus at or above the internal os. If the organ be 
unusually flabby, as it is apt to become when thus distorted, the cer- 
vix and corpus may be bent so as to lie against each other (Fig. 
226). When the cervix is drawn forward by inflammatory contrac- 
tions beside and in front of it, the flexion is usually less acute in 
degree and is distributed over the whole uterus or is confined to the 
corpus. The fundus usually does not lie as low, for in consequence 
of the previous inflammation at the cervix the uterine tissue is firmer 
and does not allow of such complete flexion. 



492 



DISPLACEMENTS OF THE UTERUS. 



Contraction of peritoneal exudates is supposed to be one of the 
most frequent causes of the extreme retroflexion represented in Fig. 
226, for such flexion occurs after inflammatory attacks (especially the 
puerperal) and is often complicated by adhesions between the fundus 
and posterior surfaces of the broad ligament with the rectum and pos- 
terior pelvic walls. I have in a few cases noted a gradual increase 
in the flexion due to a diminishing resistance of the cervical tissue 
and the increasing traction of the sacro-uterine folds. 

Because of this moderate degree of retroflexion that is usually found 
in cases of retroversion the Germans call nearly all of them retro- 



FlG. 226. 




Extreme Retroflexion. 



flexions or retroversio-flexions ; on account of the retroversion that is 
found in nearly all cases of moderate retroflexions, these latter are 
more often classed in this country with retroversions. Retroversion 
with flexion, or retroflexion with version, would not be inappropriate. 
' Some cases of flexion are due to congenital causes, but like other 
congenital deformities are rare. Flexion acquired before puberty is 
undoubtedly much more common, and is often classed as congenital. 
Malnutrition, improper feeding, sedentary habits, muscular atony and 
the like tend to arrest the development and impair the nutrition of 
the uterus. A comparison of Figs. 227 and 228 will give an idea of 



TORSION OR TWISTING. 



493 



the different kind of pressure to which the uterus is subjected in a 
woman who stands erect and one who habitually stoops. It is just 
as likely that the woman who sits and sews by hand or on a machine 
for eight hours a day during a period of several years will suffer with 
some form of uterine displacement or deformity, as that she will 
begin to stoop in her gait or suffer with dyspepsia or derangement 
of other internal organs. Continual standing also tends to uterine 



Fig. 227. 



Fig. 228. 





Natural Position of the Body. 



Unnatural or Stooping Position 
of the Body. 



flexion and displacement, because the abdominal pressure is continu- 
ous, and without that variation and general tonic effect that goes with 
varied exercise. 

Lateral flexions are usually caused by extensive contraction of 
tissue from inflammation beside the uterus, with or without tumors, 
enlargements or abscesses in or about the ovaries and Fallopian tubes. 



Torsion or Twisting. 

Torsion or twisting of the uterus to an unnatural degree may result 
from pressure or traction forward or backward at one horn of the 
uterus, or at one side of the cervix. The most common causes are a 
contraction in or about one sacro-uterine and one broad ligament (Fig. 
52), and along or near the course of one round ligament. A sim- 
ultaneous backward or forward version or flexion is also found in 
most cases — sometimes a lateral version. 



494 DBSPIiACEMENTS OF THE UTERUS. 

8 . | Uterine Displacement. 

The particular place or position of the womb may not directly give 
rise to any characteristic symptoms until the organ commences to 
press at the pelvic outlet. The coexisting displacements, distortions 
or pathological conditions of the surrounding structures, whether the 
causes or results, usually cause the great bulk of symptoms. 

When the uterus is much enlarged its weight causes irritation or 
inflammation of the tissues upon which it presses, with the symptoms 
belonging to such troubles. Traction upon tender tissues also cause 
similar symptoms. Thus retroversion by traction, and anteversion by 
pressure, upon a tender bladder, may cause vesical irritability : or 
retroversion by pressure and anteversion by traction upon a tender 
rectum may cause pain in the rectum or sacrum. 

Pains due to displacement are apt to be localized and persistent. 
and increased in certain postures and by certain occupations. Ante- 
versions and anteflexions are nearly always accompanied by decided 
symptoms, especially during the menstrual congestion, because the 
weighted uterus is suspended or held from fixed, and usually inflamed, 
tissues. Retroversion and retroflexion are much less often associated 
with painful symptoms, because the fundus finds a resting place be- 
hind, and hence does not drag so heavily upon inflamed parts. Even 
when the twisting of the broad ligament produced by the displace- 
ment is primarily painful, the state of rest of the organ often favors 
a subsidence of the inflammation, and particularly bo if the recto- 
vaginal promontory and posterior vaginal wall are high and firm 
enough to afford indirectly some support to the cervix, turned for- 
ward over them. Pain in one iliac region is often caused by the trac- 
tion of an anteverted or retroverted uterus when complicated by a 
contracted broad ligament. Constipation is often a result of the 
pressure of a retroverted organ upon the rectum, but may also be 
caused by the induration and contraction in the sacro-uterine liga- 
ments encircling the rectum in case of anteversion. 

Sterility is more often a symptom of anteflexion than of retroflexion 
or retroversion, and more often of decided retroflexion than oi retro- 
version. Extreme lateral version or flexion are also apt to be accom- 
panied by sterility, due. however, to its cause. Retroversion although 
seldom a cause of sterility is not infrequently a cause of abortion. 

Protrusion may give rise to faintness. dragging sensations about the 
pelvis, indigestion, inability to endure continuous exertion, irritability. 
hysteria, local irritation and ulceration, and in some cases renders the 
erect position unbearable, and life a burden. 

The symptoms of uterine displacement are so variable and bo inti- 
mately connected with the pelvic diseases that I do not attempt to give 
all that are observed, but enough to enable the student to understand 



DIAGNOSIS OF UTERINE DISPLACEMENTS. 



495 



their nature, and appreciate the relation of the symptoms to the dis- 
placement, which in reality is itself but a symptom among the others 
of some pelvic disease or disorder. 



Diagnosis of Uterine Displacements. 

For a diagnosis of the positions of the uterus the reader is referred 
to Chapter II. It will only be necessary here to give a few facts rela- 
tive to the differential diagnosis. One of the first and most important 
points is to determine the place and position of the cervix. Antever- 

FlG. 229- 




Anteversion and Retroversion (Schematic), after B. S. Schultze, illustrating do Changes in 

Location of the Lower End of the Cervix (£). n, normal position of uterine cavity.; 

a, anteversion ; r, retroversion. 

sion of a full-sized uterus scarcely ever exists when the lower end of 
the cervix is two inches or less from the pubic arch ; nor retroversion ' 
when it is more than two inches. Fig. 229 illustrates the changes in 
position of the lower end of the cervix in anteversion and retroversion, 
and Fig. 230 between anteflexion and retroflexion. The uterine cavi- 
ties only are represented. 

Anteflexion with retroposition or retroversion is often mistaken for 



496 



DISPLACEMENTS OF THE UTERUS. 



ordinary retroversion because the cervix extends forward in the vaginal 
axis, and its posterior wall is felt as far as the finger can reach extend- 
ing as a flat or slightly convex surface (antero-posteriorly) towards the 
sacrum (Fig. 224). By placing the finger tip against the os and rais- 
ing the side of the finger against the inferior pubic ligament in one of 
the urethral notches, it will be immediately perceived by measurement 
that there is no room for the fundus between the cervix and the sacrum 
unless the uterus be flexed. If flexed backward the fundus will of 
course be easily reached behind the concave cervical wall. If the os 
point toward the pubes or vulva and be less than two inches from the 
pubic arch there is retroversion (Fig. 229) or retroflexion (Fig. 230) or 

fig. 230. 




Anteflexion and Retroflexion (Schematic), after Schultze, showing the Changes in Location of 
the Lower End of Cervix, n, normal position ; a, anteflexion ; r, retroflexion. 



else the fundus will be reached in the bimanual examination. Should 
an anteflexed uterus be drawn too far back to be palpated bimanually, 
the tense sacro-uterine ligaments may be felt behind the cervix. 

An unusual length of the anterior vaginal wall, from the inferior 
pubic arch to the cervico- vaginal junction (over 2| inches) is diag- 
nostic of the great majority of cases of anteversion (229 a) or anteflexion 
(230 a) — it is much greater than in retroversion and retroflexion (r\ 



DIAGNOSIS OF UTERINE DISPLACEMENTS. 497 

The ease with which the fundus can be reached bimanually is of 
great importance. A knowledge of the location of the fundus, the 
vaginal junction and the external os gives as accurate information as 
to the shape and position of the whole organ, even when the entire 
anterior or posterior surface cannot be palpated. 

Retrouterine tumors are liable to be mistaken for retroflexions or 
even retroversions. The ringer should be pressed as far up the ante- 
rior and lateral cervical wall as possible in search of the body. If the 
body be not thus detected over the retrouterine mass, it should be 
searched for bimanually. Its absence of course would prove the sup- 
posed tumor to be the fundus. The probe will pass backward if it be 
the fundus, but upward over it if it be a retrouterine tumor. The 
tumors most liable to be thus mistaken are retrouterine hematocele, 
fibroid in posterior uterine wall, small ovarian tumor, faeces in the rec- 
tum, and inflammatory or malignant deposits. 

The diagnosis of procidentia is easy because the cervix and urethra 
are visible and can be probed. The uterus can also be returned and 
then palpated. In prolapse the cervix is found by the finger pointing 
almost in the direction of the vaginal axis, less than two inches from 
the pubic arch, and lying on or at the recto- vaginal promontory. The 
uterine probe passes up in the direction of the curve of the pelvic 
axis or nearly so. 



32 



CHAPTER XXX. 

DISPLACEMENTS OF THE UTERUS {Continued). 

Treatment of Uterine Displacements. — Prophylactic. 

A laege proportion of the uterine displacements and deformities are 
acquired before and soon after puberty, and the majority of those 
acquired later are from causes originating in pregnant and puerperal 
conditions. Much can therefore be done in the rearing of children to 
prevent these troubles. Fewer hours of sitting, more hours of active 
outdoor exercise are required. The menstruating girl should be taught 
to rest during menstruation. The harmfulness of retaining the urine 
uncomfortably long, and the necessity of a daily movement of the 
bowels should be impressed upon her mind. Her food should be of a 
healthful kind. Anaemia, debility, nervous peculiarities, etc., should 
receive prompt attention. Especially should the least menstrual ir- 
regularity be made the subject of watchful study. 

After a miscarriage a woman should remain in bed as long as after 
labor, and after both she should be carefully watched by the physician 
until involution is safely and completely accomplished. If she have 
at the time, or previously, suffered with laceration or inflammation of 
the pelvic tissues, she should remain in bed two or three weeks instead 
of the usual eight or ten days. Immediate repair of extensive lacera- 
tions is of prime importance. 

Treatment of Simple Dislocations, Upward, Forward and Backward. 

The treatment of displacement of the uterus upward, forward or 
backward consists almost entirely in the removal of the displacing 
cause. Pending this it is often necessary to support the uterus in its 
malposition and thus relieve the tender and perhaps rigid supports 
from the abdominal pressure and the weight of the organ. Cotton 
tampons soaked in glycerine, placed under and around the cervix in 
the morning and removed at night, form the best kind of support. 
They may be introduced through the speculum in the dorsal position, 
and should not be made of absorbent cotton which packs too hard, 
but of the best quality found in the dry-goods stores. A string should 
be attached to each to facilitate its removal. 

For elevation due to inflammatory conditions of the pelvic brim, 
one tampon about the size and shape of the terminal phalanx of the 
thumb should be placed in each lateral fornix, one or two in the pos- 
terior fornix, a flat one under the cervix, and one or two large dry ones 



SIMPLE DISLOCATIONS, UPWARD, FORWARD, AND BACKWARD. 499 

in front of the cervix, according as there is much space to fill. For 
retrolocations the tampons are placed similarly except that they are 
left out of the posterior fornix. In lateral displacements no tampon, 
or only a very small one, should be put in the lateral fornix on the 
side of the displacement, but a proportionately large one should be 
put in the other lateral fornix. They may be placed very easily by 
withdrawing the speculum slightly after the deeper ones have been 
introduced. 

They are of but little service while the patient is in a recumbent 
position, and should not be employed until the acute stage of inflam- 
mation has passed, and the patient leaves the bed. Nor should the 
pelvis be packed too full of them, for our object is not to produce con- 
stant upward pressure, which would be intolerable, but to place a 
cushion around and under the cervix upon which it may settle when 
the erect position is assumed, and which will thus receive all increase 
of abdominal pressure and render it harmless. 

After the pelvic inflammation has passed into the chronic stage an 
inflated rubber ring (Fig. 231) maybe used; that it may better accom- 



FlG. 231. 




Soft Rubber Inflated Pessaries. 




modate itself to the parts, the air may be let partly out with a pin 
and the pinhole closed with melted wax. Some of those in the stores 
have a piece of wax on the inside through which they may be punc- 
tured, and then closed by pressure. 

Some patients can wear the cotton tampons or the soft pessary con- 
tinuously, others only about half of the time. When it is not con- 
venient to replace them every night they may be left in place for 
thirty -six hours, then removed by the patient, and replaced by the 
physician after another thirty-six hours. Strings should always be 
attached to them for removal by the patient at any time that they may 
cause discomfort. 

In some cases of backward dislocations of the uterus the pressure 
of the abdominal viscera stretches and depresses the anterior vaginal 



500 DISPLACEMENTS OF THE UTERUS. 

wall and makes it desirable to introduce a retroversion pessary (see 
Treatment of retroversion) which will turn the fundus forward over 
the bladder, and will also press upward behind the pubes with its 
anterior end, such as a Hodge, Thomas, Fowler or a Schultze's sleigh 
pessary. In case the bladder be separated from the uterus so as to 
allow of an anterior vaginal enterocele, a permanent fixation forward 
of the fundus by shortening the round ligaments (see Alexander's 
operation) may become advisable. 

Descent or Lapse. 

When the uterus sinks down in the axis of the superior strait with- 
out losing its mobility, either the ligaments are relaxed or the uterus 
is too heavy. Both conditions are apt to be present. Particularly is 
this so after inflammatory conditions which have raised or drawn the 
uterus toward the pelvic walls, have been in part removed, and the 
congestion, hyperplasia or subinvolution persist, The uterine sup- 
ports, weakened partly by the inflammatory action, and partly by 
long inaction, allow the heavy organ to sink down against the rectum 
or coccyx, or thereabout, and thus become permanently overstretched 
and subject to perpetual irritation and congestion. 

The indication here is to support the uterus, and relieve the trac- 
tion by tampons and soft pessaries. The tampons are placed as 
already directed for the elevated uterus, and may be used thus until 
the irritation in part subsides. After the vagina will tolerate a pretty 

Fig. 232. 




Peaslee's Elastic Ring. 

full packing they may be introduced in Sims's position, in which the 
uterus is drawn away from the pelvic floor as far as its supports will 
comfortably allow. Some prefer, after placing two or three glycerine 
tampons about the cervix, to stuff one large piece of dry cotton or fine 
wool so as to fill the vaginal cylinder. If a little boracic acid has been 
dusted on the cotton or wool it may remain three or four days, then 
be removed and replaced immediately, or in twenty-four hours. The 
inflated soft rubber rings, Fig. 231, or Peaslee's elastic ring pessary, 
Fifr. 232, can be used later. Such support, especially that by the 
tampons soaked in glycerine, by removing the traction and irritation, 
often relieves both pelvic and uterine troubles, and promotes involu- 
tion. 



TO STRENGTHEN OR ELEVATE THE PELVIC ROOF SUPPORTS. 501 

Later, if these means fail, the uterus may be reduced by electricity 
or stimulating medicines applied to the endometrium, etc. 

Prolapse and Procidentia. 

Three indications are to be considered in the treatment of this form 
of displacement, viz. : to diminish the weight of the uterus and the 
other prolapsed structures, to strengthen or elevate the pelvic roof 
supports, and to restore or supplement the pelvic floor and perineum. 

Measures for Diminishing the Weight of the Uterus. 

When subinvolution, hyperplasia, or morbid growths occur in con- 
nection with prolapse and procidentia, they must be treated before a 
satisfactory cure can be effected. The means employed to reduce the 
size of a hyperplastic or subinvoluted uterus are strong galvanic cur- 
rents applied to the interior of the uterus, intrauterine applications of 
caustic or irritants, ergot, repair of cervical lacerations, the amputation 
of an elongated cervix, or an excision of wedge-shaped pieces from 
the external os in case the cervix be elongated supra-vaginally or en- 
larged merely in circumference. 

In a few cases the whole uterus has been removed per vaginam. 
This, as Schroeder* remarks, is not now as formidable rn operation 
as formerly, and can be easily executed when the uterus is prolapsed 
or protruded, yet cannot be considered justifiable unless malignant 
disease, gangrene, or other equally grave indications call for it, i. e., 
unless the complication, not the displacement, calls for it. 

Measures to Strengthen or Elevate the Pelvic Roof Supports. 

Operations on the Anterior Vaginal Wall. — J. Marion Sims denuded a 
V-shaped figure from the anterior vaginal wall with the apex near the 
urethra and the ends of the arms just in front and on either side of 
the cervix. The denuded strips forming the V are about a third of 
an inch wide, and when united, narrow the vagina, more particularly 
at the upper end. Emmet found that the cervix sometimes caught 
into the cavity formed under the united arms of the V and became 
retroverted or otherwise caused the patient discomfort. He therefore 
modified the denudation by converting the V into a triangle (Fig. 
233). This operation was invented for the purpose of narrowing the 
vagina, and as such has been largely supplanted by operations on the 
posterior vaginal wall. But as a means of drawing together the re- 
laxed pelvic roof-tissues and strengthening them, it is rational and 
useful, and involves less mutilation than an excision of a large oval 
or round piece of vaginal wall. It is preferable, I think, to combine 

* Op. tit. 



502 



DISPLACEMENTS OF THE UTERUS. 



such an operation with perineorrhaphy than to remove as large a part 
of the posterior vaginal wall as is frequently done in posterior colpor- 
rhaphy. 

When the parts about the urethral fossae, or lower end of the vaginal 
sulci, are the ones most relaxed, the excision of two narrow strips 
from the fossae (one on each side), diverging as they extend backward, 
may be indicated. (Fig. 234). These strips may be connected by a 
transverse strip under the neck of the bladder when there is much 

Fig. 233. 




e(W) 

The Sims-Emmet Denudation for Cystocele and Procidentia. 
A, uterus ; E, urethra ; CCCC, denuded surface. 



redundancy of the anterior vaginal wall in an antero-posterior direc- 
tion. (Fig. 235). The stitches of the transverse denudation take an 
antero-posterior direction, those of the lateral a diagonal direction, 
with reference to the vaginal axis. The object is to draw the relaxed 
vaginal wall up behind the pubes into the sulci and urethral fossa?. 

There is a peculiarity about the passing of the sutures in the ure- 
thral fossae and the lateral denudations that is worthy of attention. 
They should be passed in a direction diagonal to the long axis of the 
vagina and made to include the edges of the wound and a strip of the 



TO STRENGTHEN OR ELEVATE THE PELVIC ROOF SUPPORTS. 503 

centre, as in Fig. 236. It draws, when tightened, the edges and bottom 
of the wound up together (237). When, however, ordinary stitches 
are passed, not including the bottom of the wound, the tissues are 
folded so that the bottom is removed as far as possible from the edges 
as in Fig. 238. In denudations directly under the urethra and bladder 



Fig. 234. 



Fig. 23." 



Urethra 



Urethra, 






Ccmx 




Cervix 



Fig. 234. — Lateral Denudation in the Urethral Fossae and Anterior Vaginal Sulci, for elevating 
and strengthening the Pubic End of the Vesico-vaginal Septum. 
Fig. 2^5.— Denudation for raising and strengthening the whole Vesico-vaginal Septum. 

in the median line, the latter are better, as they make a thicker sep- 
tum. In denudations in the urethral fossse and anterior vaginal sulci 
the former are preferable because they draw the vaginal walls up to 
the connective tissue above. 

Recently gynecologists, especially the German, have gone back to 
Sims's first method of excising an oval piece of the anterior vaginal 



Fig. 236. 



Fig. 237. 



Fig. 238. 



Fig. 236.— Stitch passed so as to catch up the Bottom of the Wound. 

Fig. 237.— Same, united. 

Fig. 238.— Suture passed and united in the usual manner. 



wall and drawing the edges together in the median line. Sims used 
superficial stitches only, and sometimes had trouble from an accumu- 
lation of the secretions at the bottom of the wound. This is now 
obviated by the employment of three or four additional deep stitches, 



504 DISPLACEMENTS OF THE UTERUS. 

or by uniting the deeper portions by one or two rows of buried catgut 
sutures as recommended by Werth.* 

When soaked in oil of juniper for 24 hours, and then preserved in 
alcohol, Kiister claims that catgut will resist absorption for nine days 
(Schrceder, op. cit). A continuous suture may be taken along the 
bottom of the wound, and then another a little higher up. 

Sometimes the entire mucous membrane is denuded from the Sims- 
Emmet triangle and united by transverse deep and superficial stitches. 

Cauterization. 

Cauterization of the vagina and cervix has been resorted to for the 
reduction of redundant tissue and the strengthening or hardening of 
the uterine supports. Holes have been burnt into the cervix with 
caustic and longitudinal strips of the vagina have been cooked by the 
actual cautery and electro-cautery. 

Recently John Byrne,f of Brooklyn, has employed partial and com- 
plete amputation of the cervix and vaginal folds, by means of the 
galvano-cautery, with success. In some cases in which the pelvic con- 
nective tissue has completely lost its tone and in part wasted away, 
this method will undoubtedly prove valuable in producing a cicatricial 
hardening of the pelvic roof tissues. 

Partial Closure of the Vagina. 

Lefort's method of denuding a median strip on both anterior and 
posterior vaginal walls, two centimetres wide and six centimetres long 
(| x 2i inches), and uniting them, has proved a useful operation. The 
parts may be denuded while protruded and returned as fast as they 
are stitched, commencing of course with the deeper portions. A 
small channel for the passage of the secretions is thus left on either 
side. 

Well prepared catgut may be used, as first recommended by Panas,J 
and thus the troublesome removal of stitches avoided. 

L. A. Neugebauer's method is practically the same as Lefort's, but 
his surfaces are a trifle smaller. 

By thus practically uniting the pelvic roof and pelvic floor, the 
uterus may be supported when the vaginal outlet and the perineum 
are destroyed beyond repair. Martin has known this artificial barrier 
to give way under the strain of heavy lifting, and allow the prolapse 
to occur again. 



* Centralbl. f. Gyn., 1879, No. 23, Schrceder-Krankh. d. Weibl. Gechlechtrory, 
7th ed. 

f Transactions, Am. Gyn. Soc, vol. ii. 

X Winckel, Lehrbuch der Frauenkrankheiten. 



HYSTEROPHORES OR PESSARIES. 



505 



Abdominal Section. 

P. Mueller, T. G. Thomas, H. Marion Sims, and others, have cured 
some desperate cases by amputating the uterus above the cervix, and 
attaching the stump in the peritoneal wound. Others have attached 
the uterus and its appendages to the abdominal walls after laparotomy 
for other purposes. This latter method would hardly be attempted 
by a special laparotomy, as there would be too much uncertainty of 
the attachment holding, and too little certainty of the patient recover- 
ing from the operation. 

Measures to Supplement or Restore the Pelvic Floor and Perineal Supports 

The pelvic floor and perineum may be supplemented or restored 
for the retention of a prolapsed or protruded uterus by (1) hystero- 
phores or pessaries, and (2) by plastic operations. 

Hysterophores or Pessaries. 

The simplest yet least efficient form of hysterophore is the ordinary 
perineal band, passing over the vulva and attached to an abdominal 
supporter or broad elastic belt. Its most useful application is in con- 



FlG. 239. 




Fitch Supporter. 

nection with a large vaginal tampon, introduced in the Sims position, 
so as to fill the replaced vagina. It may be medicated with astrin- 
gents and antiseptics, such as tannin, boracic acid, a mixture of tannin 
and iodoform, persulphate of iron, Fuller's earth, etc., and may be 
changed once in two or three days, or left for five or six days, i. e. y as 
long as it remains in place and free from odor. Some patients can be 
taught to use them upon themselves, by first returning the protruded 



506 DISPLACEMENTS OF THE UTERUS. 

mass, and pushing back the cervix toward the sacrum, or by assum- 
ing the knee-chest position, and then stuffing the vagina full. 

Hackenberg, of Rochester, N. Y., precedes the tampon by tannic 
acid. The uterus is pushed as far up as practicable by the speculum 
introduced in the dorsal position, thirty grains of the tannin placed 
around the cervix and dry cotton packed in the vagina after it. The 

Fig. 240. 




Silk Elastic Belt. 

advantage of thus using the astringent is that it contracts the vagina 
instead of dilating it, as do pessaries and other kinds of tampons. Dr. 
Hackenberg claims to have made permanent cures in this way. 

Strong solutions of sulphuric acid, tannin, acetate of lead, decoctions 
of oak bark or other astringent solutions, used as vaginal injections, 
are also helpful adjuvants in producing contraction of the vagina and 
vulva. 

Such procedures are, however, not so often curative as preparatory 
to other treatment, They contract the parts, relieve the tension upon 
the uterine supports, promote involution, and thus bring the case 
within the reach of the more radical treatment. 

The soft rubber pessary introduced in the Sims position, or in the 
dorsal, sometimes exerts a beneficial influence upon the pelvic organs 
when they are congested and tender, but seldom does much toward 
curing the prolapse, as it keeps the vaginal walls distended and thus 
prevents them from returning to a natural state. 

The Peaslee, Mayer, or Dumont-Pallier elastic ring pessary, covered 
with soft rubber, is often a good temporary expedient, and in moderate 
cases gives great comfort to the patient (Fig. 232). It does not require 
frequent removal for cleansing, as does the soft rubber inflated ring, and 
may be left in place for weeks at a time, provided an antiseptic vagi- 
nal douche be used twice a day. A large glycerine or astringent tam- 
pon introduced under and in front of the cervix every morning and 
removed at night, may be employed by the patient with great comfort 



HYSTEROPHORES OR PESSARIES. 



507 



and benefit while she is wearing the elastic ring. The ring must often 
be quite large, so as to be retained by the bony pelvic walls. It then 
finds a rest against the tuberosities of the ischium and pubic rami. 

A rubber bag introduced by the patient in the knee-chest position 
and then inflated by a syringe, or a collapsed soft rubber ring may be 
similarly employed. 

A large Hoclge pessary may be used for prolapse and sometimes for 
procidentia. B. L. Schultze's modification, called the sleigh pessary, 
forms, however, a better support for the pelvic roof, and will often be 
found useful. 

Zwank's pessary (Fig. 242), which has two branches resembling 
wings, is often a convenient makeshift. It is introduced closed, and 
then expanded until the wings rest on the ischial tuberosities. It 
keeps the parts within the pelvis and gives great temporary relief. 



Fig. 241. 



Fig. 242. 





Schultze's Sleigh Pessary. 



Zwank's Pessary. 



When left too long in place it is liable to cause ulceration, and must, 
therefore, be carefully watched and occasionally removed. This incon- 
venience applies to nearly all pessaries used for procidentia. 

Of late Breisky has brought the forgotten egg pessary back into use. 

Scanzoni attached a stem with a ball to a perineal band for the pur- 
pose of holding the uterus higher in the pelvis. The Roser-Scanzoni 
hysterophore is an improvement upon the original, and has been ex- 
tensively used. In this country cups and rings have been placed on 
the stem, instead of the ball and the stem, and perineal bands have 
been made of elastic material to avoid sudden violence during muscu- 
lar exertion of the patient, or ulceration from too firm pressure. 

Cutter placed a cup on the stem to support the cervix, or an elon- 
gated ring to pass into the posterior fornix, and extended the stem out 
over the perineum and back between the nates to join a tape or rubber 
to be attached to a waistband. Thomas has improved upon the origi- 
nal one somewhat. 






DISPLACEMENTS OF THE UTEBTTS. 



Dr. Scott, of Woodstock, Canada, constructs a pessary of about the 
same shape as Cutter's. It has the great advantage, however, that it 



Fig. 243. 



Fig. 244. 





Mcintosh Uterine Supporter. 



Mcintosh Uterine Supporter Applied. 



can be made by any physician and bent to suit any mse. Take a 
piece of copper wire about a sixteenth of an inch in diameter and six- 



¥lG. W 




Thomas's Modified Cutter Pessarv. 



teen or eighteen inches in length. Slip a piece :: small but heavy 
rubber tubing upon the middle third of it. Bend the covered portion 



Fig. 2J6. 



Pre :-r 





Scott's Pessary. 



with Tapes for Attachment to a Belt. 
- hematic) 



of the wire into a ring, so that the ends of the rubber tubing will meet ; 
then twist the ends of the wire into a stem and slip another piece of 



PLASTIC OPERATIONS UPON THE PERINEUM AND PELVIC FLOOR. 509 

tubing over the twisted stem. The junction of the tubes at the upper 
end of the stem may be consolidated by filling the uneven edges with 
cotton batting, winding thread around it, and then coating it with 
flexible collodion. Then bend the ring portion into an oval shape, 
with a carve on the flat, so as to enable it to reach up behind the cer- 
vix, and bend the stem sharply back at a point about an inch from 
the lower end of the ring and give it the curve of the sacrum, so that 
it will pass up between the nates toward the waist. A tape attached 
to the end of the wire will serve to fasten it to a strip of cloth tied 
around the waist. I have thus frequently made the Scott pessary, 
and have taught the patient to introduce it before rising in the morn- 
ing and to remove it after getting into bed at night. She must be told 
to be careful in getting the ring behind the cervix, i. e., to make the 
ring sweep around the hollow of the sacrum instead of straight up 
behind the pubes. 

In some of the instrument stores, particularly in New York, a Scott 
pessary is made of hard rubber in which the ring is prolonged into 
the vulval portion, or to a point where the stem should turn back. 
In case of simple prolapse or retroversion, when the vulva is not 
dilated, this prolongation is an evident disadvantage, as it takes up 
more space in the vulva, and is liable to irritate. 

The Priestly and Lazarevitsch pessaries in the foreign market are 
also stem pessaries. 

Plastic Operations upon the Perineum or Pelvic Floor. 

Fricke, of Hamburg, united the denuded labia (episiorrhaphy) for 
the retention of the prolapsed uterus and vagina and succeeded in 
ameliorating the condition of some of his cases in which he could not 
fit a pessary.* Gerardin, of Metz, proposed in 1823 to denude two 
opposite surfaces at the lower end of the vaginal canal and unite 
them.f Meude proposed the formation of an artificial h}^men. Dief- 
fenbach denuded surfaces on the lateral vaginal walls and united 
them. Malgaigne made denudations higher up. 

These attempts were of course unsatisfactory because they merely 
converted a procidentia into a prolapse or lapse. Simon was the first 
to attempt to hold the uterus at its normal elevation in the pelvis by 
narrowing the vagina. Fig. 248 shows the original Simon denudation 
and the various modifications since employed for prolapse, and which 
have been referred to under the chapter on Perineorrhaphy. To these 
may be added those of FritschJ and Reamy,§ which will be under- 
stood by an examination of Figs. 249 and 250. 

* Lageversenderungen, etc., des Uterus. Fritsch. 

f Lehrbuch der Frauenkrankheiten. Winckel. 

X Op. cit. \ Medical News, April 9, 1887. 



510 



DISPLACEMENTS OF THE UTERUS. 



Hegar's is the best of the median operations. It forms an un- 
naturally large perineal triangle and a high, long recto-vaginal pro- 



ne. 248. 




Outlines of Denudation for Procidentia. After Winckel. 

montory. Martin's is the best of the bilateral operations. None of 
them, however, are suited to the child-bearing woman. One of the 



Fig. 249. 



Fig. 250. 





Denudation for Procidentia. After Fritsch. 



anus 

Denudation for Procidentia. Alter Rearav. 



TREATMENT OF VERSIONS. 511 

other operations described in the chapter on Perineorrhaphy would 
be preferable as forming less obstruction during a subsequent labor. 

Choice of Methods. 

As the object to be accomplished in the management of prolapse 
and procidentia is not merely to push the parts back from the vulva, 
but to restore the normal condition and relationship of the pelvic, and 
to a certain extent the abdominal viscera, a combination of the dif- 
ferent procedures already recommended will usually be necessary. 
When the causative condition is found, that, of course, should receive 
the first attention. 

Nulliparous cases should if possible be treated without any mutila- 
tion of the vulva and vagina. Uterine enlargement in the subacute 
or progressive stage should be treated with remedies designed to re- 
move all congestion and inflammation, and the organ supported by 
vaginal tamponment or packing. Chronic subinvolution, hyperplasia 
or elongation of the cervix must, when present, receive separate treat- 
ment before the uterus can be permanently replaced. 

The strengthening of the supports by astringent vaginal and rectal 
injections, and the simultaneous or subsequent use of tampons and 
pessaries should also be thoroughly tried. If these be not sufficient, 
shortening of the round and sacro-uterine ligaments* or both, may be 
employed together with the tampons or pessaries. 

AVhen the patient has borne children, as is almost always the case, 
we should look for injuries, and results of injuries, in parturition. If 
we find a laceration of the pelvic floor or perineum, we must not, how- 
ever, think that the misplacement will necessarily be cured when that 
is repaired. The same attention must be given to all the factors as in 
treating nullipars, and all congestions, enlargements and subinvolu- 
tions of the genital organs reduced as far as possible, that they may 
not reproduce the difficulty. The operation upon the perineum and 
pelvic floor may be among the last steps in the cure. Operations 
upon the pelvic roof structures must often precede them. 

When rational treatment cannot be carried out, sometimes Lefort's 
or Neugebauer's operation combined with an Alexander operation 
may be performed, and the patient rendered much more comfortable. 

Treatment of Versions. 
I. Anteversion. 

Anteversion, being usually symptomatic of contraction or pressure 
of tissues outside of the uterus, or of enlargement about the fundus or 
anterior wall, is relieved by the treatment of these pathological states. 

* See Treatment of Eetroversions. 



512 DISPLACEMENTS OF THE UTERUS. 

Vaginal Tamponment. 

Abdominal or vaginal supports should be used as soon after the 
causative inflammatory or other conditions will permit, not so much 
for the purpose of replacing the uterus as to relieve the traction or 
pressure upon tender or indurated places. Hence the vaginal tampon 
should be preferred to the pessary, which is apt to press uncomfort- 
ably and constantly over limited areas. The tampons, in order to 
relieve the tender or rigid parts of the weight of the uterus or force of 
abdominal pressure, must sometimes temporarily favor or even increase 
the malposition. Thus if sacro-uterine ligaments be rigid or con- 
tracted, the tampons are placed under and in front of the cervix, so as 
to keep the cervix back, and up, and prevent it dragging upon them. 
They may thus increase the version. When, however, the fundus is 
pressed down by abdominal pressure so as to irritate the bladder or 
painfully twist the cervical attachments, then the corpus, or both 
corpus and cervix, should be raised to a position of comfort. When 
the round ligaments or their surrounding tissues are tender and con- 
tracted, the plugs should hold the cervix and fundus in the position 
in which they are thus drawn. When the weight of only a part of 
the uterus is at fault, the tampons must, of course, aid in supporting 
the weighty portion. 

Anteversion 



When the deposits and contractions have been removed, then the 
uterus will need no pessary or support for the anteversion, not only 
because the anteversion would then be painless and harmless, but 
because the anteversion will usually cease to exist. The uterus may 
return to a normal or, what is usual, pass to a state of lapse, prolapse, 
retroversion, or other malposition, and thus require a pessary or other 
treatment for its new position. The anteverted uterus is usually 
hardened and heavy, or we would have an anteflexion at the same 
time. The disappearance of the disease about the contracted sacro- 
uterine or round ligaments is apt to be followed by their relaxation, 
and a consequent movement either of the cervix too far downward 
and forward, or of the fundus too far back. A lapse or prolapse 
follows in the first case, while a retroversion may easily be produced 
in either. 

When, however, a pessary is used it should be used on the same 
principles as the tamponment, viz., to give the pelvic organs relief 
without reference to the malposition. When the retention of the 
uterus in a normal position gives greatest relief, then, and not until 
then, should it be so held by a pessary. 

In this country, Gehrung and Thomas, and in England, Hewitt have 
invented the most popular forms of anteversion and anteflexion pes- 
saries. Thomas has invented several varieties. In my own practice 



ANTEVERSION PESSARIES. 



513 



I utilize my own model of retroversion pessary (see Retroversion, Fig. 
256), by bending the neck or collar a little further forward than for 
retroversion, as in Fig. 254. I thus can make it support the cervix, or 
lift the body, as much or as little as desirable by altering the size, 
position, and shape of the collar. When the vesico-vaginal septum is 



Fig. 251. 



Fig. 252. 





Gehrung's Pessary for Anteversion. 



Hewitt's Anteversion Pessary. 



firm, it does not reach the corpus, but pries up the fundus by the 
traction of the elevated septum upon the cervix in a forward direction. 
When the cervix is to be supported merely, a small sized one with the 



Fig. 253. 



Fig. 254. 




B - r «Mfl7f/W 



Thomas's Anteversion Pessary. 




Byford's Pessary with the Neck Elevated 
for the Relief of Anteversion. 



retroversion shape may be used, Fig. 256 or 257. Thomas's elastic 
soft rubber modification of the Albert Smith pessary, with a pad for 
retroflexions, Fig. 270, can often be satisfactorily bent into this shape. 
Sims's operation of denuding a surface in front of the cervix, and 
another a little lower down and stitching them together, so as to 
shorten the anterior vaginal wall, is, it seems to me, an unscientific 
procedure for anteversion or anteflexion, and does not affect the parts 
involved in their production except to create traction upon the cervix. 
It can only overcome such displacement by force. Sims's method of 

33 



514 DISPLACEMENTS OF THE UTERUS. 

denuding the anterior lip, and uniting it to the anterior vaginal wall 
farther down, is still less scientific. 

I formerly modified the Albert Smith retroversion pessary by elon- 
gating the tongue or anterior end, and bringing it out over and under 
the perineum, so as to prevent the instrument slipping too far into the 
vagina. By then making the vaginal portion sufficiently short, it held 
or pried the lower end of the cervix forward and corrected the malpo- 
sition. At the point where the bars passed through the vulva, they 

Fig. 255. 



"Rcctuza 




Anteversion Pessary acting by holding the Lower End of the Cervix Forward. 

were made to touch each other, and thus occupy but little space. The 
discomfort experienced by the patient from having the cervix thus 
dragged forward, led me, however, to abandon such treatment. It 
corrected the misplacement, but often increased the irritation, which 
should have been subdued. 

II. Retroversion. 

The treatment for retroversion here given is equally applicable to 
retroversion with slight retroflexion. 

In the Acute and Subacute Stages. 

Before the uterus is replaced, acute and subacute inflammatory con- 
ditions should be removed. When the uterus and vagina become 
tolerant of cotton tampons medicated with glycerine, they may be 
used with great benefit. At first it is better to place a soft one under 
the cervix, in order to relieve the cervical supports of the strain, which 
the abdominal pressure bearing upon the exposed vesico-vaginal 
septum must occasion— particularly so in the standing posture. But 
the tampon should not be pushed back in the fornix so as to press 
upon tender ovaries or retrouterine tissues. In many cases the con- 
tinuance of localized pelvic inflammations renders all other mechanical 
support than this impossible for a long time. 

Replacement 

After the inflammation has subsided an attempt may be made at 
replacement. This is done by pushing the cervix back, or the fundus 



ADHESIONS. 515 

upward, or both. The most common method employed is to introduce 
two fingers into the vagina and push upward against the fundus 
through the posterior cul-de-sac with one, and backward against the 
cervix with the other. It is very difficult to reach far enough with the 
finger in the posterior fornix to get the fundus above the sacrum, hence 
the finger against the cervix has to do the principal work. I usually 
find it more efficacious to depend entirely upon leverage, and accord- 
ingly press the middle finger in the vaginal fornix backward under 
the fundus toward the lower end of the sacrum. The posterior vaginal 
wall is thus made to draw the upper end of the cervix back, while the 
forefinger pushes back the lower end. After the cervix is well back 
the other hand over the abdomen should, if possible, be caught over 
the fundus and be used to pull it down over the pubes, and complete 
the replacement. Sometimes two fingers in the rectum may be used 
to press up the fundus, and the thumb of the same hand in the vagina 
to push back the cervix. 

Another method of replacement, advocated by Campbell,* is to put 
the patient in the knee-chest position and admit air to the vagina. If 
the fundus is not immediately drawn up into the abdomen it may be 
pushed out of the hollow of the sacrum by the fingers or by any thick 
blunt instrument. 

In case the vaginal portion of the cervix is too short or soft to afford 
any leverage, or the uterus too flabby to be forced or pushed up, I 
sometimes introduce a stem probe, which is practically the same as a 
hard stem pessary (Fig. 269) and then am not only able to replace the 
uterus by leverage, but can tell by the position of the lever end of the 
stem just where the fundus has gone to. This method is valuable in 
determining the presence or extent of adhesions, and is much less 
severe upon some patients than the bimanual. Some gynecologists 
use the probe or an intrauterine repositor for the purpose of reposit- 
ing the fundus. Such methods are more hazardous for any but the 
experienced to employ, and are seldom a necessity. 

Adhesions. 

When the uterus cannot be thus replaced, or when the fundus will 
rise only a certain distance before encountering firm resistance, or 
causing the patient great pain, it is probably held by adhesions. 

Adhesions are of two kinds, viz: (1) direct adhesions between the 
peritoneal surfaces of the uterus and its appendages to their surround- 
ings, and (2) indirect adhesions, as cicatrices or contractions in the 
cellular tissue about the uterus preventing it from returning to a 
normal position. Both kinds may sometimes be overcome, especially 
if recent, by treatment directed to the absorption of the abnormal 

* Transactions American Gyn. Soc, vol. i. 



516 DISPLACEMENTS OF THE UTERUS. 

tissues. In the chronic stage the first may be materially influenced 
and sometimes overcome by intermittent or constant traction, while 
the second kind are only slightly benefited thereby. 

The Vaginal Pack. 

In the subacute and chronic stages of the inflammation producing 
the adhesions, and after the pelvic tissues will tolerate moderate pres- 
sure, the retroversion is benefited by the vaginal pack or tamponment. 
We then no longer rely on the mere cervical support of a glycerine 
plug, but we pack the posterior and lateral fornices with antiseptic 
cotton so as to support the whole organ. The cervix is not merely 
pushed back and tamponed there, for that would tend to increase 
whatever flexion or tendency to flexion might exist, and create dis- 
comfort, but the fundus is pushed well up, and the posterior fornix 
filled with two or three dry pieces of wool or cotton (not the absor- 
bent). Then, if there be room, a small flat tampon saturated with 
glycerine or oil is placed on each side of the cervix, a larger one under 
it and perhaps one in front. The vaginal entrance should, however, 
be free of all packing or pressure. 

When the uterus is quite movable the packing may be more advan- 
tageously placed in the knee-chest position. The fundus and ovaries 
will then be out of the way during the packing and will settle on the 
pack more comfortably. 

The first packing should be loose and small, and should not distend 
the vagina, nor should subsequent ones ever be so large as to cause 
discomfort, Engleman* uses medicated cotton for the purpose of 
getting a medicinal effect upon the pelvic organs as well. 

When the fundus can be replaced by the knee-chest position the 
pack should be so arranged as to hold the cervix well back and thus 
retain the organ in as normal a position as possible. 

If properly placed it may remain from two to five or six days. If 
any tendency to irritation or ulceration due to the packing be discov- 
ered the cotton or wool should be lubricated and should not be re- 
newed for a day or two after being removed. 

Breaking Up of Adhesions. 

B. S. Schultze f recommends the breaking up of adhesions under 
chloroform narcosis. He introduces two fingers into the rectum and 
the thumb into the vagina, and after repositing the uterus sufficiently 
to put the band of adhesions on the stretch, breaks them slowly by 
hooking the rectal fingers over them. Flat adhesions are separated by 
the rectal finger as the placenta would be separated from the uterine 

* American Journal of Obstetrics, June, 1887. 
f Op. cit. 



MECHANICAL SUPPORT. 517 

wall. Flat adhesions of the uterus to the rectum are often difficult to 
separate because the rectum may be drawn forward with the uterus. 
Adhesions of the tube and ovaries to the sacrum require delicate 
handling and should be separated by a slowly increasing pressure. 
Usually they cannot, with a safe amount of pressure, be separated at 
one sitting, but may be tried again, provided no reaction follows the 
first trial. 

In subacute cases we may usually get the uterus free by treatment 
directed to the absorption of the plastic deposits. In chronic cases I 
have for weeks, and sometimes months, employed vaginal and bi- 
manual manipulation once or twice a week to break up the adhesions. 
By sweeping the vaginal finger-end from side to side between the ad- 
herent rectum and uterus, and drawing up the uterus until the pain 
became quite severe, I have usually succeeded in freeing the fundus 
so that it could be lifted up but not always forward. The difficulty 
is that when the patient can endure such manipulations the adhesions 
are too chronic to be completely separated in this way. I have also 
partly liberated ovaries and tubes, and have, by no other treatment 
than this, supplemented by a glycerine tampon and the vaginal douche, 
caused all dysmenorrhcea and pelvic symptoms to disappear, together 
with the cervical ulceration and congestion. But the vast majority 
of cases that come to me require a long course of treatment before such 
manipulations can be tolerated. 

Recently Polk * has recommended and performed laparotomy for 
the purpose of breaking up the adhesions in old, obstinate cases, 
accompanied by great suffering, and has succeeded in relieving 
the symptoms. In case the uterus requires support, he follows the 
laparotomy by an Alexander-Adams operation. I prefer making a 
vaginal incision into the recto-uterine pouch, and breaking them up 
through that. I have done so in four cases, but have each time found 
it advisable to remove the diseased ovaries and tubes at the same time. 
In the last two cases I held the uterus in place by vaginal tampons, 
and thus cured the displacements. 

Mechanical Support. 

After all inflammatory reaction and obstructing adhesions or con- 
tractions have been removed from the pelvic tissue, the uterus has a 
tendency to return to its normal position. Many times, however, the 
sacro-uterine and round ligaments remain relaxed and weakened, and 
have not the power of turning the fundus forward after an evacuation 
of the bladder, or of preventing a backward displacement during 
straining in a stooping posture, as in defecation, lifting, etc. It may 
be reiterated here that during muscular exertion a greater strain is 

* American Journal of Obstetrics, June, 1881. 



518 DISPLACEMENTS OF THE UTERUS. 

often thrown upon the uterus than its suspensory supports can bear 
(crowding it down against the pelvic floor), while during muscular 
relaxation but little power is required to return and hold it in a nor- 
mal position. 

As a consequence, much advantage will be gained by supporting 
the uterus until stretched ligaments have become retracted, and any 
chronic indurations or cicatrizations sufficiently absorbed or stretched 
to allow the corpus uteri to incline over the bladder without restraint. 
Mechanical supports or pessaries accomplish this by taking advantage 
of the pivot or ball-and-socket action of the cervical supports, and pry 
the fundus forward by turning the cervix backward. They may be 
divided into four classes : (1) those acting in front of the cervix by 
keeping it in the back part of the pelvis ; (2) those acting behind the 
cervix by drawing the cervix backward; (3) those combining the 
action of both of the above methods, and (4) those acting similarly 
upon the cervix within its canal. 

Pessaries Acting in Front of the Cervix, or Barrier Pessaries. 

The advantages of pessaries acting in front of the cervix are that 
they interfere but little with the natural uterine supports, restrict but 
slightly the normal motions of the uterus, and can be removed and 
introduced by the patient. 

The great disadvantage of this form of instrument is that it requires 
the fundus to rest without restraint in front of the superior strait so as 
to receive the abdominal pressure upon its posterior surface. When 
from lateral or other traction, or retroflexion, the fundus does not re- 
main well forward, abdominal pressure, which at times is all-powerful, 
will turn the fundus back and either pry the cervix over the barrier, or 
else pry up the barrier out of place. A short vaginal portion of the 
cervix, short anterior vaginal wall, a flabby uterus, tenderness in front 
of the cervix, are also not uncommon conditions that limit its useful- 
ness. These barrier-pessaries, therefore, find their chief use after other 
more powerful supports have been used, and it has become desirable 
to partly withdraw the artificial support and allow the uterine liga- 
ments to assume function. They supplement but do not supplant the 
ligaments as do the firmer supports. They are especially useful after 
labor, at which time the size of the uterus affords them greater advan- 
tage. In case of laceration of the cervix they should especially be 
tried, as they both lift the cervix from the posterior vaginal wall and 
hold the torn lips together. 

On account of the possibility of a retroversion occurring while they 
are apparently in proper place, the patient should assume the knee- 
chest position two or three times in twenty-four hours and admit air 
to the vagina, and thus replace both, uterus and pessary in case they 
should be displaced. 



BARRIER PESSARIES. 519 

The simplest form of the barrier pessary is a piece of ordinary cotton 
loosely rolled in the shape of a spool of thread, and introduced over 
and behind the rectal promontory, in front of the replaced cervix. It 
should be changed once in twenty-four or forty-eight hours, when an 
antiseptic vaginal douche may be used. Having been thus used for 
a time it may be removed at night and another introduced in the 
morning. The patient may even learn to introduce it herself in the 
knee-chest position ; or in the knee-elbow position after having thus 
replaced the uterus. She can of course remove it by first attaching a 
string to it. 

Similarly a collapsed rubber ring may be introduced by the patient 
in the knee-elbow position after thus replacing the uterus, and then 
inflated. 

Courty's barrier pessary consists of two bars resting on the pelvic 
floor, joined in front where they impinge against the pubes or vaginal 
entrance by a cross bar, and curved up posteriorly around either side 
of the cervix so as to meet in front of it. The neck thus made for the 

Fig. 256. Fig. 257. 




Byford's Retroversion Pessary. Byford's Retroversion and Prolapse Pessary. 

cervix forms a rigid barrier to keep it back. Dr. T. P. Fitch of this 
city, without having seen Courty's instrument, invented, during an 
extended series of experiments, an instrument similar to it. 

By turning the posterior end of an Albert Smith in front of the cer- 
vix I devised an instrument which, although I did not know of 
Courty's pessary, was practically a modification of it (Fig. 256). The 
difference lay in the tongue shape of the anterior end, the curving of 
the bars to correspond to the posterior vaginal wall or (if that were 
relaxed) the pelvic floor, and the depression of the middle portion of 
the collar for the reception of the cervix. The consequent action of 
the pessary is elastic, for a slight rocking motion is allowed by the 
curved arms. Where there is danger of the pessary slipping, the arms 
may be separated and the tongue curved back under the pubes, as in 
Fig. 257. Fig. 258 shows the pessary in place. 

It may be introduced turned sideways or upside down, or any way 
in which it enters best, until the collar passes behind the pubes, and 



520 



DISPLACEMENTS OF THE UTERUS. 



then turned right side up. The patient can easily place it by intro- 
ducing it far enough for the collar to rest behind the pubes, and then 
assuming the knee-chest position and allowing it to slip into position. 
She can remove it by turning it partly around and giving it a little 
twist as she withdraws it, or by turning it upside down and rolling or 
prying it out. On account of the difficulty in altering the arms so as 
to fit the posterior vaginal wall in the hard rubber instrument, I have 
so far made my instruments out of the soft rubber, elastic, Thomas 
and Albert Smith pessaries or, when a large one was required, out of 
the largest size ring of copper wire covered with soft rubber, as found 
in the shops. 

Fig. 258. 




Byford's Retroversion Pessary in Place. 



By depressing the collar the barrier may be placed in front of the 
lower end of the cervix and get a powerful leverage upon the fundus ; 
by raising the collar the barrier holds the whole cervix back, but gets 
less of the leverage power. The straighter the arms the less is the 
rocking motion and the firmer and more rigid the barrier. During 
defecation it is always advisable for the patient to press the finger 
against the end of the pessary and prevent its coming forward, and to 
assume the knee- chest position afterward. 

I have had better success in permanently curing retroversions with 



TRACTION PESSARIES. 521 

this pessary than with an} T other. Its inefficiency in many cases is in 
accord with its non-interference with uterine motion, for it allows the 
uterine ligaments to resume healthy motion. 

Pessaries acting behind the Cervix, or Traction Pessaries. 

The advantages of the pessaries acting behind the cervix are that 
they take a firm hold upon the posterior vaginal wall, and draw the 
cervix up as well as back, and thus prevent ordinary abdominal 
pressure from bearing upon the anterior uterine wall and reproducing 
the displacement. Contractions beside the uterus which prevent the 
barrier pessaries from acting efficiently, have but little effect in repro- 



FiG. 259. Fig. 26 





The Albert Smith Retroversion Pessary. Hodge's Closed Lever Pessary. 

ducing the displacement when the traction pessaries are used because 
of the firm elevation of the cervix. Another advantage is their me- 
chanical simplicity, and the ease with which they can be successfully 
used by the general practitioner. 

Their disadvantages are that they are apt, by distending the vagina, 
to weaken the pelvic roof ; they draw the cervix higher than natural 
and thus interfere with the normal action of the supports ; they are 
apt to retrovert the uterus when removed by the patient, and they 
cannot be replaced by the patient. In proportion as they are modified 
to lessen these disadvantages they become either less efficient or more 
difficult of adjustment. They are, however, and will probably remain 
the most generally useful pessaries for retroversion. 

The Hodge closed lever pessary is the oldest and most efficient of 
the almost infinite varieties to be found in the shops. It consists of 
an elongated ring bent somewhat abruptly upward behind the cervix, 
and more gently upward in front, so as to impinge against the ante- 
rior vaginal wall behind the pubes. It is liable to turn in a roomy 



522 DISPLACEMENTS OF THE UTERUS. 

vagina and to find inefficient support against a relaxed vesico-vaginal 
septum. These disadvantages have been overcome in the Albert 
Smith pessary by narrowing the anterior end of the ring, and turning 
it down so as to project slightly under the pubic arch. An increase 
in the curve of the arms elevates the cervix, increases the anteversion, 
and renders the pessar}^ mechanically more efficient. A separation of 
the bars diminishes the tendency to turn sideways and slip out at the 
vulva. 

As an excessive elevation of the cervix is unnatural and often 
harmful and unbearable, Emmet diminishes the length and abrupt- 
ness of the posterior upward curve. He also employs a larger bar 
than others. Hewitt's retroversion pessary is simply an elongated 



Fig. 261. 




Hewitt's Cradle Pessary. 

ring with a gentle curve on the flat. It is particularly useful when 
the vagina is small, but it is liable to press injuriously behind the 
pubes. Schultze's sleigh pessary is a modification well adapted to a 
relaxed vagina. (See Fig. 241.) 

The Scott, Thomas, Cutter, Priestly, and Lazarewitsch pessaries 
with external supports are also valuable when the relaxed vagina 
does not retain the other forms. (See Figs. 245, 246.) Hanks, Noege- 
rath, Schroeder, Gehrung, and others have devised other slight modi- 
fications. 

The ordinary material for such pessaries is the hard rubber. The 
Albert Smith pessary is made also of spring wire covered with soft 
rubber, and constitutes an excellent instrument for the general prac- 
titioner. Any form, however, may be given to the copper wire rings 
covered with soft rubber, and after a thorough and satisfactory trial 
may be reproduced by the instrument dealer, in hard rubber. 

Pessaries Acting both in Front and Behind the Cervix. 

The advantages of pessaries acting both in front and behind the 
cervix, are a firmer grasp of the cervix, and a dividing of the force 
between the traction and pressure. They are particularly applicable 
when the posterior vaginal wall is relaxed and voluminous, or when 
the cervix is lacerated. The disadvantages are an unnatural confine- 



PESSARIES ACTING WITHIN THE CERVICAL CANAL. 523 

ment of the cervix, difficulty of adjustment, and a tendency to injuri- 
ous pressure. 

Fritsch places a bar (which projects slightly upward) across a 
Hodge pessary at about the junction of the posterior and middle 
third. 

Studley, and T. D. Fitch, place a ring on a Hodge or Albert Smith 
pessary, so as to project forward from the posterior upper end and 
encircle the cervix. 

Schultze twists an elongated ring into a figure eight, the upper or 
cervical end of which is a little smaller than the lower. He then 
curves the upper ring slightly on the flat so that the concavity looks 
upward, and the lower so that the concavity looks downward; or 
gives it any special curve that the case may require. The cervix rests 
in the upper ring. Objection has been made to the pessary on account 
of its interference with copulation. I have not used it. 

Thomas places a semicircular bar upon the upper half of an 
Albert Smith pessary, and thus gets an anterior bearing upon the 

Fig. 262. Fig. 263. 





Thomas's Retroflexion Pessary. Fowler's Pessary. 

cervix without confining it as much as those just mentioned. When 
the cervix is flabby or lacerated, this form is often very useful. 

The Fowler pessary has a circular opening for the cervix, and is 
otherwise thick and solid, excepting a small hole in the tongue in 
front. It is very much the shape of a cadet cap turned upside down, 
and rocks upon the posterior vaginal walls, as do the others. 



Pessaries Acting within the Cervical Canal. 

Retroversion and retroflexion pessaries acting within the cervical 
canal, are usually of the Albert Smith or Hodge variety, with an 
intrauterine stem attached to a cross bar, or resting in a cup or sup- 
port. 

The only true pessary of this kind with which I am acquainted, is 
one invented by H. Marion Sims.* There is no projection into the 
posterior fornix, but the stem is attached to the posterior end or cross 
bar, and moves forward and backward on it as a pivot. He intro- 



Araerican Journal of Obstetrics, June, 1886. 



524 



DISPLACEMENTS OF THE UTERUS. 



duces it in the Sims ? s position. When the stem is in the uterus, it 
carries the cervix back and tilts the fundus forward as the ring is 
pushed into place in the vagina. The Byrne, Thomas, and Kinlock 
instruments have the posterior projection of the Hodge or retraction 
pessaries, and are therefore a combination of both varieties. 



Fig. 264. 




Marion Sinis's Retroversion Stem Pessary. 



Those in which the stem has a hinge, or ball-and-socket motion upon 
the cross bar, are safer and hence preferable to those in which the stem 
is fixed firmly upon the cross bar. 

The advantages of this form of pessary are those that belong to the 
uterine stem (see Treatment of Flexions, and of Dysmenorrhcea), and 
which aid in making the cure of the replacement permanent. 

The disadvantages are the great danger of the use of the intra- 
uterine stem in general, and of the application of the force by so small 
a rod. 

Since writing the above description, I have learned* that Dr. S. J. Donaldson, of 
New York, had used a similar instrument about three years before Dr. Sims, but with- 
out his knowledge. 



American Journal of Obstetrics, August, 1887. 



CHAPTER XXXI. 

DISPLACEMENTS OF THE UTERUS {Continued). 

Operative Procedures for Retroversion. 

Operative measures for the relief of retroversion are (1) for the pur- 
pose of restoring the uterus to its natural condition, (2) of restoring 
the function of the uterine supports, and (3) of holding the fundus 
forward or the cervix backward (operations of expedience.) 

To Restore the Uterus to its Natural Condition. 

Enlargements of the uterus and cervix may be treated by the same 
operations as already recommended for prolapse and procidentia. 

To Restore the Function of the Uterine Supports. 

Not only are the sacro-uterine and round ligaments the ones which 
prevent retroversion and replace the temporarily retroverted uterus, 
but they are the ones always found relaxed or elongated. Therefore 
the shortening of these ligaments may be resorted to as a cure for 
the misplacement. 

Shortening of the Sacrouterine Ligaments. 

I have so far only attempted to shorten the sacrouterine ligaments 
in two cases, but obtained such satisfactory results in one case that I 
consider the subject worthy of farther study. The following is the 
method that was employed. With a pair of small tenaculum forceps 
I drew the cervix forward until I could feel the somewhat tense sacro- 
uterine ligaments by a finger of the other hand. An assistant then 
held the forceps while I introduced a stitch, by the aid of the touch, 
along the sacrouterine ligament so as to grasp an inch or more of it. 
In order to accomplish this I used a long heavy needle slightly curved 
from eye to point, and sharpened only about the point.* It was grasped 
in Fritsch's needle holder so that the chord of the arc formed by the 
needle was almost parallel with the long axis of the holder (Fig. 265). 
Some difficulty was experienced, for the needle point had to be intro- 
duced into the vaginal covering of the cervix just below the attach- 
ment of one of the ligaments, carried up to the ligament and then 
backward along the ligament (as felt upon the finger) into the back 

* A round point requires too much force to push it through the connective tissue. 
I bent one the first time I tried it. 



526 DISPLACEMENTS OF THE UTERUS. 

part of the pelvis. After carrying the point as far back as the finger 
can follow, the traction upon the cervix was removed and the posterior 
vaginal wall pushed back as far as possible, so that the needle when 
brought through it would include as little vaginal wall as might be. 

Fig. 265. 




Needle Mounted upon Fritsch's Needle-holder for Introducing Sutures into the Sacrouterine 

Ligaments. 

So far I have merely tied the stitch about the puckered vaginal wall 
that is included. Had I not done them as secondary to another 
operation and been fearful of interfering with the main operation, I 
should either have excised a fold of the vaginal wall between the 
entrance and exit of the needle, or should have made a vaginal in- 
cision along the track of the sutures, from each stitch hole a third of 
the way to the other into which a part of the suture would have 
sunk. In the first case I used silkworm gut, in the second catgut, 
and obtained the best results with the former. In each case there was 
a lacerated perineum, and relaxation of all the uterine supports, so 
that but for a cicatricial contraction in the left broad ligament, the 
cervix would have come through the vulva. In each instance I short- 
ened only the right sacrouterine ligament, or that upon the side oppo- 
site the cicatricial contraction. A cotton tampon was placed in front 
of the cervix, removed each day for a vaginal douche to be given, and 
then another tampon introduced. 

In the case in which I used the silkworm gut the cervix is now 
held higher from the pelvic floor than normal, when the pessary 
(which she still wears) is removed. Although six months have elapsed 
I have not removed the pessary except temporarily because she has 
been obliged to carry coal up a long flight of stairs and do her wash- 
ing and ironing almost from the time she left the hospital, and also 
because the uterus is still larger than natural. In the other case, in 
which catgut was used, although the fundus is held forward by the 
shortened round ligaments, the cervix still comes forward, although 
not to the same extent as before, I am led to believe from my experi- 
ence with these cases that a shortening of both ligaments would often 
give satisfactory results in cases of retroversion, and in cases of pro- 
la pse or even procidentia would be efficacious in connection with the 
operation upon the round ligaments and, if necessary, the perineum. 

As to the dangers of this procedure, only a few drops of blood es- 
caped, and no reaction followed. If the point of the needle be not 
allowed to get far from the finger end, there is not much danger of 



THE ALEXANDER-ADAMS OPERATION. 527 

injuring the rectum or upper intestines. Before the needle is pulled 
through, an assistant should introduce the finger into the rectum for 
the purpose of making sure that the needle has not punctured it. 
Septic matter might also be carried to the peritoneum on the point of 
the needle and would constitute a danger in case antiseptic precautions 
were not taken. Possible dangers might arise from breaking the needle, 
or losing track of the point and puncturing the intestines or blood- 
vessels, or from carelessly operating upon a ligament surrounded by 
inflammation or induration. 

The operation could undoubtedly be more easily done by making 
an opening into the cul-de-sac large enough to admit one ringer as a 
guide. The point of the needle could then be made to enter the' cul- 
de-sac through the cervical attachment of the sacrouterine ligament 
and to enter the ligament again at any desirable distance back of 
this, and thus gather up a fold ; and after being drawn through it 
could be either so tied, or reintroduced into the ligament from the 
peritoneal side near the cervix and be brought out into the vagina near 
its point of entrance, and then tied. 

This is perfectly justifiable when the cul-de-sac is already opened 
for the removal per vaginam of an ovary lying under the retroverted 
corpus ; and perhaps by means of a special opening in extreme cases. 
The abdominal cavity would be almost entirely shut off by the over- 
lying uterus. The stitches could both be passed before lifting the 
fundus, and then tightened one immediately after the other. The cul- 
de-sac could then be sponged or washed out and closed or, if any ooz- 
ing were noticed, drained. 

I have performed the operation upon the cadaver by way of the ab- 
dominal cavity with the result of producing anteversion of any degree 
desirable. It could be done on the living subject through a low incision 
that would admit one hand and two fingers of the other, and might 
be justifiable in cases in which the abdomen was already opened for 
other purposes, such as removal of the appendages, etc. 

Shortening the Round Ligaments, or the Alexander- Adams Operation. 

The Alexander-Adams operation, or shortening the round ligaments 
for the relief of certain cases of retroversion, is based upon true scien- 
tific principles, for it restores the action of the relaxed round ligaments 
in drawing the fundus uteri forward, and bringing the abdominal 
pressure to bear upon the posterior surface of the uterus. The abdomi- 
nal pressure then relieves the ligaments of their burden except for oc- 
casional short periods of time. It is, however, unscientific to depend 
entirely upon the operation when the sacrouterine ligaments are greatly 
at fault, for means should be taken to restore them also to function. 
When the sacrouterine ligaments are chiefly at fault they should, if 



528 DISPLACEMENTS OF THE UTERUS. 

possible, be shortened first, and if the round ligaments cannot then be 
made to renew their function they may be shortened afterward. 

Shortening the round ligaments was suggested by Alquie* of Mont- 
pellier, but was not successfully performed on the living subject until 
December 14, 1881, by W. Alexander of Liverpool. Jas. A. Adams of 
Glasgow, without a knowledge of Alexander's operations performed it 
in Glasgow in 1882. It has now been performed over two hundred 
and fifty times. 

Indications. 

The indications for the operation are a persistence of retroversion 
(or retroflexion) with distressing symptoms after a failure of other 
means. In case of prolapse it is occasionally indicated, as a secondary 
to other operations when the round ligaments allow the fundus to fall 
back toward the sacrum. 

Contraindications. 

Among the contraindications are the following : all conditions that 
prevent the placing of the uterus in a position of anteversion without 
discomfort to the patient; adhesion of the broad ligament or Fallopian 
tubes to the back part of the pelvis ; acute and subacute pelvic inflam- 
mation, a tense state of the round ligaments while the uterus is retro- 
verted, and an enlarged ovary and tube that are not drawn up by the 
replaced uterus. 

The Operation. 

The operation consists in cutting down upon the terminal ends of 
the round ligament at the external inguinal ring, drawing them out 
until they are felt to move the previously replaced uterus, cutting off 
their redundancy and stitching their ends into the wound. 

An incision from one and a half to three inches is made from the 
pubic spine along the upper edge of Poupart's ligament. After cut- 
ting through the skin and a layer of subcutaneous fat, the deep layer 
of the superficial fascia is encountered. In fleshy people another 
layer of fat is found under this about half as thick as the first. In 
slender women this deeper layer of fat is often very insignificant, so 
that we come almost directly to the coarsely striped intercolumnar 
fascia covering the ring. We may know the ring by its tendency to 
bulge, and at the same time by its depressibility on pressure. The 
depression immediately under Poupart's ligament does not bulge, has 
a harder bottom, and is less definite in shape. 

The intercolumnar fascia should be incised in the direction of the 
external wound, but only from the pubic spine to the external edge 
of the ring. 

The superficial epigastric and external pubic, which are generally cut, seldom re- 
quire a ligature, as they are easily controlled by the Langenbeck serre-fine (Fig. 157). 

* Aran, Traite" des Maladies des Femmes. 1858. 



THE ALEXANDER-ADAMS OPERATION. 529 

For the purpose of operating rapidly without the fear of cutting too 
deeply, I have had a pair of scissors made, bent on the side, and with 
an extended probe-point on the under blade. When a fascia is cut 
down upon, or cut through, this point is slipped either over or under 
it, and the incision extended by one cut as far as desirable. 

In fleshy women a ball of fat, somewhat smoother and more delicate 
in appearance than that we have encountered before, will fill the field ; 
in slender patients, however, the round ligament will be found lying 
in full view near the external pillar and spreading out toward the 
pubic spine. It is pinkish-white and round, and frequently has the 
small white glistening genital branch of the genito-crural nerve lying 



Fig. 266. 




Byford's Probe-pointed Scissors for Cutting Fascia. 

upon it. When the field is filled with fat the ligament usually lies 
imbedded in it, or surmounted by it. The fat should therefore be 
pulled or dissected off and the ligament be sought close to the inferior 
edge of the ring. If the mistake is made to poke down into the canal, 
the ligament will not be easily found, for it there resembles the ten- 
dinous bands and aponeurotic edges closely and descends rapidly 
beneath them. 

When the round, pinkish, slightly mottled ligament cannot be dis- 
tinguished from the muscular and aponeurotic edges, there are two 
sensations which belong to the ligament when grasped by the forceps 
that may help in finding it, viz. : the ligament usually feels elastic 
when pulled, and it bleeds but little when loosened from its surround- 
ings. The aponeurotic edges may be pulled out a certain distance 
and then may resist suddenly, and if pulled much harder, break, 
while the round ligament resists pulling in a more gradual or elastic 
manner. Everywhere that the aponeurotic or muscular edges are 
separated blood oozes from the torn surface. 

When the ligament has been seized by the forceps at the inguinal 
ring, it is so intimately attached to the external (inferior) pillar by its 
fibres, and their connective tissue or fascial covering, that it will be 
necessary to thrust the scissors-point through this thinner membranous 
portion, connecting the ligament with the edge of the ring, in order to 
hook up the ring. I have had a hook constructed that is widened 
and flattened in the curve so as to present a surface of one-eighth of 
an inch to the ligament, and is sufficiently sharp on the point to 
penetrate the connective tissue under and about the ligament without 
any previous puncture. With this the ligament may be lifted and 

34 



530 DISPLACEMENTS OF THE UTERUS. 

put upon the stretch, while with a fine pair of scissors curved on the 
flat, we clip off the loose fibres that connect the sheath with the ingui- 
nal canal. We should then use the fingers in preference to the hook 
in pulling upon it. If, after loosening the ligament as far as we can 
see, it does not "peel out" or "run," we may slit up the canal for a 
short distance in order to continue the separation. If the ligament 
still cannot be made to run by moderate traction, we must dissect off 
its entire sheath for a short distance all around and then draw it out. 
After one ligament is thus separated so as to run, it should be dropped 
and a clean sponge laid in the wound until the other ligament is 

Fig. 267. 



Byford's Broad Hook. 

loosened. It is better, as Alexander has suggested * to stand on the 
side opposite to the incision that is being made in order to be able to 
look deeper into the canal. 

The ligaments being loosened, the next step is to replace the uterus 
by the finger, a sound, or an intrauterine stem, and have it so held by 
an assistant. The ligaments are then drawn out until they are felt to 
move the uterus. Not infrequently the inverted sheath is drawn into 
view and must be peeled back out of the way. 

The next step is to stitch the ligament to the ring. This may be 
done by three medium-sized juniper catgut sutures passed from the 
external or internal side of the ring through the round ligament to 
the opposite side. When tied loosely so as not to constrict the liga- 
ment, they close the upper external end of the ring and incised edge 
of the canal, and leave room for a small drainage-tube underneath. 
I then cut off the superfluous portion of the ligament and attach the 
divided ends by a catgut suture. In my last two cases I have used 
silkworm catgut. 

Alexander! "stitches each (ligament) to both pillars of the ring by two sutures on 
each side," cuts off the "chafed ends" and stitches the remainder " into the wound by 
means of the sutures that close the external incision." 

I then introduce a small drainage-tube into the canal under the 
ligament, dust a little iodoform into the external wound and sew it up 
with silk. One of the external sutures is passed deep enough to in- 
clude the ligament. A one per cent, solution of carbolic acid is then 
injected into the tube to more completely cleanse the deeper wound, 
and an antiseptic dressing of iodoform gauze, cotton smeared with a 

* British Gyn. Journal, Part III., November, 1885. 
f Op. cit. 



THE ALEXANDER-ADAMS OPERATION. 531 

ten per cent, solution of carbolic acid in glycerine, or the equivalent, 
should be placed over the wound. A Hodge or Albert Smith pessary 
which has been previously fitted should be introduced, and, if the 
uterus be much flexed, a stem pessary. 

The drainage-tube should be taken out as soon as the discharge of 
bloody serum has ceased, viz. : in twenty -four to forty hours. Its 
track should, however, be first washed out by another injection of the 
carbolic acid solution. If the dressings become saturated they may 
be changed before that time, and once in twenty-four hours after. 
Union by first intention may then be expected in patients that are not 
too fat or too poorly nourished. After all discharge has ceased I use 
a dry iodoform dressing. 

The stitches should be removed in five or six days and a few adhe- 
sive straps applied. 

After- Treatment 

The patient should be kept in bed between two and three weeks, 
and should not walk until after three weeks nor perform any hard 
work until after six or eight weeks have elapsed. The stem pessary 
should be worn from two to three months, the vaginal pessary from 
three to twelve months, or until the sacro-uterine ligaments become 
contracted so as to hold the cervix back in place. 

Results of the Operation — Cases. 
My own experience extends to ten cases, seven performed by 
myself and one by my assistant, Dr. Carrie N. White, at the clinic in 
the Woman's Hospital. 

In the first case, Miss B w, aged 24, there was a slight irreducible retroflexion. 

Pessaries could only be tolerated for a short time before causing distress. Five years 
treatment, the last two by myself, had failed to put her in a condition to do the house- 
work for herself, mother and brother. Dysmenorrhea, attacks of uterine colic and 
vesical tenesmus from once to twice a month had confined her to bed for a day or two 
each time, previous to the operation. The pessary was removed six weeks after the 
operation. Glycerin tampons worn about half of the time for a month longer, and then 
about two days out of the week. At first the cervix hung low, so as to reach almost to 
the coccyx, but the fundus remained in front of the pelvic axis. The first two or three 
menstrual periods were painful, but since then she has steadily improved. Dysmen- 
orrhea, uterine colic and bladder symptoms are all gone. The sacro-uterine ligaments 
have contracted somewhat, so that both the cervix and fundus are now (over a year 
after the operation) normal in position, although a very slight retroflexion persists. 
Is now able to do her work. (Woman's Hospital.) 

In the second case, Mrs. K p, the results were not so satisfactory. The opera- 
tion was performed for the relief of severe dysmenorrhea and backache combined 
with sterility that was getting worse in spite of treatment. There was a gonorrheal 
salpingitis of right side with some contraction in upper part of the broad ligament. 
No pessary could be found that would keep the uterus in place during the performance 
of her household duties. She was unwilling to submit to a salpingotomy. The liga- 
ments were easily drawn out, but the operation was followed by an acute attack of local 



532 DISPLACEMENTS OF THE UTERUS. 

peritonitis or peri-salpingitis, probably due to the breaking up of adhesions. Highest 
temperature 101° F., on fourth day. Walked across floor twenty-three days after the 
operation without discomfort. Menstruated seven weeks after operation with less pain 
than usual. Pessary removed in six weeks. About a week after, the uterus became 
retroverted while she was leaning over the stove, and another attack of peri-salpingitis, 
with excessive nausea, followed. Highest temperature, 101 f° F. Saw her next day 
and reintroduced a pessary. Fallopian tube felt in right sacral pouch, enlarged. 
Temperature normal on seventh day. Had a slighter attack at the beginning of next 
two menstrual periods. Substituted a Thomas for the Albert Smith pessary. She has 
had no acute attack since, and is now, eleven months after the operation, free from 
her old backache (which has not troubled her since the operation), and menstruates 
without pain, and is satisfied if she can remain as well as now. She still wears the 
Thomas pessary. (Woman's Hospital.) 

In the third case, Mrs. D , the subinvoluted uterus seemed to be held in retro- 
version by the weight of the enlarged right ovary and tube lying in the cul-de-sac of 
Douglas. The cervix appeared at the vaginal entrance whenever the pessary was left 
out for any length of time The operation was followed by no disagreeable symptoms. 
The pessary was removed after three months and left out for a few days, but was rein- 
troduced because the cervix came forward and the enlarged uterus literally hung upon 
the round ligaments. The ovary and tube could not be reached by the vaginal finger. 
The pessary was removed after seven months, and the uterus found slightly retroverted 
the next day. When replaced it remained temporarily in a normal position, showing 
that the ligaments, although unable to hold the heavy uterus and ovaries up during 
active exercise, were not relaxed as before the operation. The ovary followed the 
uterus. The pessary was replaced. (Private family.) 

The fourth case, Mrs. T , is one in which a cicatricial shortening of left broad 

ligament (due to a lacerated cervix with subsequent inflammation) was all that pre- 
vented a procidentia. The left ovary and tube were adherent to the broad ligament, 
the right ovary slightly enlarged and lying in the rectouterine peritoneal pouch. 
Moderate right diagonal laceration of the perineum and pelvic floor, relaxing the pel- 
vic outlet. Subinvolution. She had been treated by two prominent gynecologists, but 
obtained no relief. None of us could fit a pessary that could be tolerated. It had 
been proposed to remove the appendages. In operating I found the left ligament 
enlarged to about twice the normal diameter by the increase of connective tissue, and 
the right one much smaller than usual. A pessary was from that time worn without 
discomfort, except from its tendency to protrude. Four weeks after the operation 
unilateral perineorrhaphy was performed. After this the uterus hung upon the broad 
ligament, with the cervix just behind the newly-formed recto-vaginal promontory, 
and before it was considered safe for her to wear a pessary the right ligament had 
relaxed so as to allow the right horn to swing back a little. The left side held. She 
now wears a small Hodge pessary (seven months afterward) with comfort, and feels 
belter than for years. The old ovarian pain, for which' the appendages were to be 
removed, is gone. (Woman's Hospital.) 

The fifth case, Mrs. H e, was one of subinvolution and retroversion with con- 
traction in the left broad ligament and relaxation of all the others. There was also a 
rectocele due to an uncicatrized transverse perineal laceration. A Scott pessary was 
the only one that could be used with any benefit. I relieved the rectocele by a plastic 
operation, and was then able for awhile to hold the uterus in position with a Hodge 
pessary. But in a short time the perineum began to relax and the uterus turned 
backward over the pessary, no matter how much I increased the size. I preceded the 
Alexander operation by a stitch in the right sacrouterine ligament, taken with silk- 
worm gut. The cervix was held back by vaginal tampons for the first ten days and 



THE ALEXANDER-ADAMS OPERATION. 533 

afterwards by a much smaller sized Hodge pessary than those that had before failed 
to do so. All symptoms of ill health rapidly subsided, and she was doing her washing 
and housework in two months after the operation. She feels entirely well. The 
cervix remains higher in the pelvis than normal when the pessary is removed. On 
account of the enlargement of the uterus and the amount of hard work she is obliged 
to do I have not yet thought it safe to remove the pessary. It is six months since the 
operation was performed. (Woman's Hospital.) 

In the sixth case, Mrs. S , performed over five months ago, the retroversion 

resisted the pessary treatment for a year, and was accompanied by backache and in- 
ability to perform her household duties with comfort. She was anxious for relief. I 
was unable to make the ligaments run satisfactorily, but removed three-quarters of an 
inch from each, and inserted the stitches so as to draw the ligaments a little farther 
out. The inguinal ring was literally filled with veins and small arteries. Notwith- 
standing the failure to satisfactorily shorten the ligaments, the uterus was more com- 
pletely anteverted by the pessary than before, and now remains in a state of ante- 
version when the pessary is removed. The result could not have been better had I 
removed three inches of ligament. The pessary is still worn. (Woman's Hospital.) 

In the seventh case there was a contraction of the left broad ligament, and a small- 
ness of the vagina (although she had borne an illegitimate child a number of years 
before) that made all pessaries either useless or intolerable. The ligaments were only 
about half the normal thickness, and were made to run with difficulty. She still wears 
the pessary. Improvement was gradual. Two months after the operation she was not 
able to work as well as before. Four months after she could work better. (Woman's 
Hospital.) 

Case eight was one of extreme retroflexion, in which pessaries were useless ana 
could not be tolerated. No trouble was experienced in the operation, except the ad- 
justment of the pessaries. A hard rubber intrauterine stem to control the tendency of 
the uterus to double up or "recoil," and a small, well-curved Hodge pessary were 
finally made to hold the cervix and uterus in their proper relations with the fundus. 
The stem slipped out two or three times during the first three weeks, but soon lost 
that tendency. Two months after the operation the pessaries were removed, but as 
there was still a tendency to flexion and a relaxed condition of the sacrouterine liga- 
ments the Hodge was again introduced. (Woman's Hospital, Dr. White.) 

Case nine was one of extreme retroflexion of a flabby uterus. An intrauterine stem 
was used. She was doing her housework in two months completely relieved of all 
symptoms. (St. Luke's Hospital.) 

Case ten is too recent to be reported. (Woman's Hospital.) 

A study of these cases has led me to expect less of the operation, 
but (expecting less) to regard it as one of the most valuable of the 
recent additions to minor gynecology. It is applicable scientifically 
to only a small percentage of cases of retroversion and retroflexion, 
and then is often only an aid to other measures, or one among others; 
but as such it gives most satisfactory results. When employed as a 
sole remedy it frequently fails, but when employed as a step toward 
the cure, preceded and followed by other appropriate and no less 
necessary treatment, it does not disappoint. Perhaps its most strik- 
ing result is the comfort and benefit with which a pessary (including 
the intrauterine stem) can be subsequently worn. If the operation 
did nothing else it would still have a just claim to recognition as a 
scientific procedure. In view of the recurrence of the displacement 



534 



DISPLACEMENTS OF THE UTERUS. 



in my second case I consider it safer to leave the pessary in the vagina 
from six to eight months. This prolonged use of the pessary is par- 
ticularly indicated when a contraction in or about a broad ligament 
prevents the uterus lying comfortably in a position of moderate ante- 
version. Theoretically, such a contraction would contraindicate the 
operation, but practically there is often nothing better to be done; and 
there is a better prospect of a final adjustment of the tissues than 

without it. 

Dangers and Difficulties. 

When properly performed there is almost no danger connected with 
Alexander's operation; when carelessly or ignorantly performed 
hemorrhage, peritonitis, interfascial suppuration and pyaemia are 
liable to result as from any operation. Pysemia from suppuration 
occurring in the deeper portions of the wound has been the cause of 
most of the deaths. A drainage tube to the bottom of the wound 
and removed in twenty-four hours is no hindrance to union by first 
intention, and avoids the retention of the sero-sanguineous oozing 
that always follows during the first few hours after the operations. 

The difficulties are numerous to the beginner, but rapidly vanish 
by a minute study of the various steps. It is better to see it per- 
formed before attempting it, or else to study it upon the cadaver. 

Raising of the Perineum or Pelvic Floor. 
As the perineum and pelvic floor play an important part in sustain- 
ing the pelvic viscera, the uterus cannot be expected to remain in 



Fig. 268. 




Curves of Posterior Vaginal and Rectal Walls after a poorly performed Perineorrhaphy. Dotted 
lines show the normal curves, the heavy lines the faulty ones. 

proper place when they are relaxed or lacerated. Hence any course 
of treatment looking to a permanent cure of retroversion should not 
leave these parts out of consideration. But not only must the vaginal 
outlet be restored, but the muscles and fasciae must be drawn together 



OPERATION FOR HOLDING OR FIXING THE CERVIX BACKWARD. 535 

so as to form a firm and resistant as well as a high recto-vaginal pro- 
montory against which the cervix will find rest and the uterine liga- 
ments be relieved from tension during the action of strong abdominal 
pressure. The fibres and fascia of the levator ani under the rectum 
must also be raised or pulled forward to their normal place, and 
the lower curve of the posterior rectal wall (see Figs. 31 and 54) be 
restored. 

The shape of the denudation is determined by the location and 
extent of the relaxation (see chapter on perineorrhaphy). The vaginal 
walls, the pelvic floor, the perineum, separately or simultaneously as 
a whole, or in a particular region, may be at fault, and require the 
operation to be chiefly within the vagina or entirely about the vulvo- 
vaginal entrance. 

Operations of Expedience. 

These operations fix the fundus forward or the cervix backward, 
and although seldom strictly scientific may be useful as substituting 
a lesser evil for a greater one. 

Abdominal Section for Fixing the Fundus Forward. 

Abdominal section for the cure of retroversion or retroflexion 
usually has for its object the stitching of the upper end of the uterus, 
the cornua, the round ligaments or their appendages to the abdominal 
wall above the pubes. Koeberle was the first to perform it while 
operating for removal of the ovaries. Since then it has been done by 
Mueller, Lawson Tait, Skene Keith, Heywood Smith, William H. 
Byford, Hennig, Czerny, Bardenhauer, H. A. Kelly, Polk and others. 

It is as a rule not justifiable to open the abdominal cavity primarily 
for the cure of retroversion, yet, as Olshausen, Kelly, Polk and Hey- 
wood Smith have maintained, it does occasionally become necessary 
in extreme cases, after other treatment has failed. The chief criticism 
to be made is that a fixed anteversion or anteflexion is substituted, 
and that those who have opened the abdominal cavity particularly for 
this purpose have not always tried every other means. 

Olshausen* and H. A. Kellyf suspend both uterine horns, utilizing 
the broad ligament, round ligament and the Fallopian tube, if their 
function is no longer needed, and employ from two to three sutures 
on either side. William H. Byford depends mainly upon the round 
ligaments. 

Operation for Holding or Fixing the Cervix Backward. 

It has been attempted to cause cicatricial contraction of the pos- 
terior vaginal wall by cautery (Amussat), to obtain adhesive inflam- 
mation between the cervix and posterior fornix, and to unite these 

* Centralb. f. Gyn., No. 43, 1886. f Medical News, December 4, 1886. 



536 DISPLACEMENTS OF THE UTERUS. 

tissues by denuding them and stitching them together (Lowenthal, 
Hunter, 0. E. Herrick). As a secondary procedure in rare cases the 
last mentioned one may be worth remembering. Stitching the anterior 
lip of the cervix and the upper end of the anterior vaginal wall to the 
posterior vaginal wall, while the uterus is held in moderate antever- 
sion, may also be of occasional use in connection with it. The vagina 
must of course not be occluded. The Sims-Emmet triangular opera- 
tion upon the anterior vaginal wall (Fig. 233) is occasionally appli- 
cable to retroversions. 

Treatment of Uterine Flexions. 

What has been said about the treatment of uterine versions applies 
also to flexions, and will be sufficient if the flexion be moderate. 
When it is congenital or extreme in degree and accompanied by dys- 
menorrhea (q.v.), other treatment may be indicated. 

In the congenital variety means for normally developing the mus- 
cular and sexual system are of especial importance, such as massage, 
walking, out-door games, gymnastics, association with the opposite 
sex, marriage, pregnancy, etc. Dilatation by Peaslee's or Hanks' 
dilators, commencing with the smallest, relieves the dysmenorrhcea, 
stimulates the uterus and often cures the sterility. Compressed slip- 
pery elm tents (Fig. 96) curved to suit the shape of the uterine cavity 
are often preferable because of their curve, and because they can be left 
in place from one to several hours and thus act as a powerful stimu- 
lant. If the uterine substance be hard, violence must not be done to 
it by forcing a hard straight dilator into it. If these means be in- 
efficient and the uterus remain small, flexed or flabby, without any 
signs of inflammation, the uterine stem may be tried, partly to splint 
the uterus or hold it straight, but principally to act as a powerful 
stimulant. 

Fig. 269. 




Jackson's Intra-Uterine Stem. 

In case of acquired flexion or that coming on after puberty, or after 
childbirth or abortion, a stem may be necessar}^ to hold the uterus 
straight that the pessary in the vagina may become effective. In the 
eighth and ninth cases of the Alexander operation already reported in 
this chapter, its use was well illustrated as necessary to render both 
the shortening of the ligaments and the Hodge pessary effective. The 
stem should not as a rule be attached to the other pessary. 
• If the uterus be hardened the stem must have a similar although a 



TREATMENT OF UTERINE FLEXIONS. 537 

slighter curve than the uterine cavity. If the uterus be flabby it may 
be straightened by the probe and a straight stem slipped in beside the 
probe as far as the constricted point, and pushed farther in as the 
probe is withdrawn. It is easier to introduce it with a Sims's speculum, 
or in the dorsal position without a speculum, so that it can be held in 
place by the finger until the vagina closes upon it. The stem should 
be of hard rubber or whalebone from an eighth to a sixteenth of an inch 
in diameter, and a quarter of an inch shorter than the uterine cavity. 
It should have a button-shaped or globular piece on the vaginal end 
to protect the vagina and keep it from passing too far into the uterus. 
Jackson's soft rubber stem is useful in developing the uterus, prevent- 
ing stenosis and favoring the occurrence of pregnancy, and is less apt 
to do harm in inexperienced hands. It of course has less power than 
the hard ones to immediately straighten the uterus, and is of less 
assistance to a retroversion pessary in holding the organ in its natural 
place and position. 

Anteversion and anteflexion pessaries have been variously modified 
for the treatment of flexions. Thomas has thickened the posterior end 
of the Albert Smith pessary and given the arms a sharper curve so as 

Fig. 270. 




Thomas's Bulb Eetroflexion Pessary— Elastic. 

to form a high broad rest for the retroflexed body of the uterus. Fig. 
270 represents the same, made of spring wire and covered with soft 
rubber. The retroversion pessaries acting both in front and behind 
the cervix (page 523) are also useful in retroflexions as they get a 
firmer hold on the cervix and vaginal fornices. Anteversion pessaries 
may be modified anteflexion so as to press farther in front of the cervix 
and thus by lifting the bladder produce an effect upon the upper por- 
tion of the uterus. 

In applying tampons for flexions we should avoid making use of 
ordinary leverage force applied to the end of the cervix, as that would 
only increase the flexion. In retroflexion we apply one or two tam- 
pons behind the cervix, and push them high up along its posterior 
surface so as to fill as near as possible the angle formed by the flexion. 
We then push the cervix back against the tampons (which in turn 
lift the fundus), and fill the vagina in front of the cervix, as recom- 



538 DISPLACEMENTS OF THE UTERUS. 

mended by Thomas. If it be desirable to lift the whole organ we may 
also put a small tampon in each lateral fornix beside the cervix and a 
soft flattened one under the end of it. For anteflexions the tampons 
are placed as for anteversion, except the lower or anterior ones are made 
a little larger in order to press up the tissues toward the part of the 
uterus above the curve, and also to fill the angle. 



CHAPTEK XXXII. 

DISPLACEMENTS OF THE UTERUS (Continued). 

Retroversion and Retroflexion of the Uterus during Pregnancy. 

The uterus is sometimes found retroverted or retronexed during 
pregnancy. When small during the first few weeks of pregnancy, its 
existence is not observed because it produces no inconvenience, and it 
is not until it grows large enough to partly or completely fill up the 
pelvis that anything is known of it unless discovered by accident. If 
it is examined at such time, the os uteri will be found against the 
symphysis pubis, sometimes but little above the arch, but occasionally 
as high as the top of that junction. If the uterus is retroverted fully, 
the mouth looks upward and forward ; if retroflexion exists, the os is 
still at the symphysis, but its opening is directed downivard and for- 
ward. In this last case the cervix is bent upon itself at a sharp angle, 
the lower extremity as before remarked looking downward and for- 
ward, and the uterine extremity turned backward and downward. So 
that the difference in these two conditions consists in the bent state of 
the cervix, and not in the position of the uterus. The body of this 
organ has its axis reversed almost completely, the fundus extremity 
running through the lower bone of the sacrum, while the upper ex- 
tremity of the axial line passes out of the abdomen above the sym- 
physis. The body lies in the hollow of the sacrum included in the 
peritoneal cul-de-sac between the vagina and the rectum. Both these 
canals are compressed, the rectum hard against the sacrum and the 
vagina up against the pelvic bone. The direction of the vagina is 
upward and forward instead of backward, its usual course. The finger 
cannot be made to sink deep into the vagina except behind the pubis ; 
in introducing, it turns upward and forward. The urethra runs up in 
close contact with the symphysis pubis, and is narrowed very mate- 
rially by extension and pressure, so that it very imperfectly performs 
the function of a viaduct from the bladder. 



Although pregnancy usually corrects misplacements of the uterus, 
such is not always the case, for this condition is sometimes a mere 
continuation of its unimpregnated position. It is well understood by 
accoucheurs also, that in the early months of pregnancy the normal 
position of the organ is depression, and that prolapse and retrover- 
sion are not unusual effects of recent impregnation. Under certain 



540 DISPLACEMENTS OF THE UTERUS. 

circumstances this last deviation is not corrected by the advance of 
growth in the organ. Where other causes co-operate, a distended 
bladder may aid in causing the uterus to assume and retain this posi- 
tion, as may also loaded intestines pressing upon the fundus and 
anterior face. These causes and perhaps others operate to bring about 
a gradual displacement, but there are some that produce the condition 
suddenly. It should be remembered that it is only at a certain time 
that these sudden causes can produce the effect, and that is after the 
end of the third month and before the beginning of the fifth month. 
It is about this time that the uterus attains a bulk sufficient to partly 
or entirely fill up the pelvic cavity. If when it has attained this size, 
a sudden impulse is imparted to the fundus and anterior face of the 
organ, the fundus imay be crowded so low into the hollow of the sacrum 
as to reverse the axis. In this state the forces acting in favor of cor- 
rection are feeble and may fail to bring it about. Strong abdominal 
pressure upon the intestines and bladder under tenesmus, falls upon 
the feet or breech, lifting heavy weights, and even severe sneezing and 
coughing, are occasionally causative. In the cases where the efficient 
causes are suddenly applied, the symptoms are acute and established 
at once. In the other cases the train of symptoms gradually make 
their appearance. 

Symptoms. 

When induced suddenly the patient is seized with great pain in the 
back, with a sense of weight upon the perineum, constipation, reten- 
tion of urine, tenesmus, dragging sensation in the loins, and often, 
though not always, sickness of stomach and vomiting. If gradually 
established, the pains, constipation, and retention of urine are slowly 
established, requiring from seven to twenty-one days or more, to ren- 
der them intolerable. I knew a case caused by a woman riding all 
day in railroad cars without urinating. 

There are two important symptoms, viz., retention of the urine and 
of the fseces ; from these result most of the distress complained of. 
Great distension of the bladder and the terrible suffering thereby pro- 
duced, is the worst. The student should bear in mind that quite fre- 
quently this symptom is deceptive. The urine is constantly dribbling 
from the meatus, and the patient thinks, and will say, she passes 
plenty of urine. The fact of this constant slight discharge should 
cause us to suspect that the bladder is distended ; it does not occur 
when the bladder is empty ; it is not sufficient to prevent it from being 
distended. Indeed, I do not now recollect any condition but overdis- 
tension that causes it. Retention of fseces is not productive of so great 
trouble as the other, but is attended with more less inconvenience. 

Great pelvic distress, with stillicidium urinse, are almost characteristic 
of retroflexion or retroversion, when recent pregnancy exists. 



RETROVERSION AND RETROFLEXION OF THE UTERUS. 541 

Diagnosis. 

This is usually not difficult. The first, a very important consid- 
eration, is the existence of pregnancy. Upon making vaginal examin- 
ation, immediately upon introducing the finger it comes in contact 
with a tumor. The pelvis is filled up by it in the posterior and lower 
part so that the finger is directed upward and forward. Very high up 
the vaginal cavity is quite small from pressure, at its extremity ; in 
contact with the pubis is the os tincse, very firmly held in its place. 
The tumor is round, elastic, and smooth ; not so hard as fibrous tumors, 
more central than ovarian, and more uniformly round than extra- 
uterine pregnancy. It may be ascertained in most instances, also, 
that the tumor is larger toward the sacrum than the symphysis. 

Termination. 

When left to itself retroversion may terminate in abortion, when 
the contents of the uterus will be expelled and the symptoms thus 
relieved ; or the bladder may be ruptured, the urine being discharged 
in the peritoneal cavity, causing painful death ; or the uterus may be 
ruptured, and its contents discharged in the cavity of the peritoneum, 
giving rise to fatal peritonitis ; or the foetus and its membranes may 
be surrounded by fibrinous material, the patient recover, and these 
substances remain there enveloped; or, inducing local suppurative 
inflammation, be discharged by exulceration. Sometimes the tenes- 
mus becomes so great as, by the violence of the efforts, to break 
through the posterior walls of the vagina and uterus, and discharge 
the contents through the vulva from this artificial opening. Inflam- 
mation sometimes arises without being initiated by any of these dis- 
astrous accidents, and less suddenly causes the death of the patient. 
1 think there can be no doubt but that there are very rarely cases of 
spontaneous reposition, recovery, and completion of the term of ges- 
tation. 

The prognosis is unqualifiedly bad if left to nature, but equally 
favorable if intelligently treated at the proper time. 

Treatment. 

The main thing to be done is to replace the uterus. This can very 
generally be accomplished. The attempt should not be delayed, as 
the uterus is constantly increasing in size, and the impaction becom- 
ing more certainly greater, increasing the difficulties as well as dangers. 
To facilitate the replacement, the bladder should be emptied by the 
catheter when practicable, and the faeces removed from the rectum. 
This takes away some of the obstacles. Sometimes the urethra is so 
tortuous in its course, and the walls compressed so completely to- 
gether, that a catheter will not enter the bladder. An elastic catheter 
will sometimes pass the obstruction when the metallic will not; which- 



542 DISPLACEMENTS OF THE UTERUS. 

ever we may use should be urged forward with the utmost gentleness, 
bearing in mind the great danger of perforating the attenuated 
urethra. The patient should be placed upon her knees and chest, or 
on the left side, with the left arm behind her, the thighs strongly 
flexed, and the right drawn up close to the abdomen and thrown for- 
ward. She should be placed on a table or the edge of a bed, so that 
the genital organs are easily controlled by the operator. In this posi- 
tion we may often succeed in replacement by the hand alone. The 
right hand should be well lubricated, and all the fingers be intro- 
duced into the vagina, so that the palmer surface is turned to the 
sacrum. The tumor is thus pushed up very gently and slowly, with 
the pulps of the fingers pressed closely upon the face of the sacrum, 
as high as the hand may be made to reach. There are not many cases 
in which the fingers will fail to carry the fundus above the promon- 
tory of the sacrum. When thus elevated it suddenly starts up and 
assumes the normal position. If, however, the fingers do not reach 
high enough for this purpose, a collapsed gum-elastic bag or bladder 
may be carried up between the fingers and the uterus, and, when 
elevated as much as we can reach, the bag may be inflated sufficiently 
to raise the uterus high enough. I have succeeded in* all the cases I 
have tried with this method, and I think, when the impaction is not 
so great as to preclude dislodgment, that it will almost invariably 
succeed. Some surgeons recommend the introduction of the empty 
bag into the rectum, and inflating it there, and pushing it up ; others 
introduce a drumstick, with the end cushioned and lubricated, into 
the rectum, and, pressing it against the uterus, elevating it in that 
way. Again, an instrument is used not unlike two drumsticks, some- 
what curved, attached together. The attachment confines the ends 
very near each other. The end of one of the branches goes into the 
rectum, and the other into the vagina. Thus arranged they pass up 
and carry before them the uterus. These expedients are very sure, 
but rough, and not a very safe means of arriving at the results. I 
think as much force in a proper direction can be applied by the 
fingers and elastic bag as it is judicious to employ in such cases. 
There are other methods of proceeding, but I do not think it neces- 
sary to mention any other, as these will suffice when reduction is 
practicable. 

In all these efforts to elevate the fundus we may fail, and then we 
may evacuate the uterus. This can generally be done by passing a 
bent probe through the mouth of the uterus far enough to rupture the 
membranes, and permit the escape of the liquor amnii. This being 
done, abortion will soon ensue. Puncturing the uterus with a trocar 
through the vaginal wall I can conscientiously only mention, for I 
can hardly think the operation ever commendable or necessary. The 
cervix is probably hardly ever so inaccessible but that some form of 
bent instrument can be made to enter it. 



CHAPTEE XXXIII. 

DISPLACEMENTS OF THE UTERUS (Continued). 

Inversion of the Uterus. 

Inversion is the turning of the uterus inside out, with the fundus 
down and the cervix up, a reversion of its surfaces and ends. It is 
partial or complete. When partial, the fundus is depressed in all 
degrees, from a mere indentation to a considerable protrusion through 
the cervix and os uteri. The depression of the fundus, or partial in- 
version, passes into complete when the whole organ, fundus, body, 
and neck, have passed through the mouth, and hang down below it. 
It presents a recent and a chronic form. The recent may be regarded 
as extending through the first two weeks ; after which, the circum- 
stances and condition of the uterus and patient become what they re- 
main in the future, however long it lasts. The uterus, in that time, 
has been condensed by contraction and involution to such an extent 
as to make the case permanent and difficult of change, except to dimi- 
nution and further condensation. Inversion almost invariably occurs 
anterior to or at the time of the removal of the placenta, but several 
hours, and, in very rare cases, several days may elapse before it is 
complete and discovered ; for it is quite probable that in these in- 
stances partial inversion or greater or less depression of the fundus 
had existed from the time of delivery. It is believed by different 
parties that there are two modes observed in the process of inversion. 
Sometimes the fundus is indented or depressed in the cavity of the 
body like the bottom of a "junk bottle," the depression rapidly or 
slowly increasing until it is completely down. At others, the whole 
of the fundus, and, more or less, the whole of the body, are firmly 
contracted, while the cervix remains flabby and relaxed. In this con- 
dition a slight amount of abdominal tenesmus will drive the con- 
tracted part down through the relaxed cervix ; and thus initiated, it 
requires but a continued action of the fibres of the organ and abdomi- 
nal muscles to finish the process. The causes of inversion are not 
always obvious, as cases have occurred under circumstances when 
least expected from any discoverable reasons, and inversion fails to 
be brought about by circumstances that are usually enumerated as 
sufficient. We occasionally meet with instances that have no history, 
and neither patient nor physician can give us a clear idea of the time 
or manner of the occurrence. Such a case was a subject of litigation 
in this city a few years since. And other cases are recorded in virgins, 



54-4 DISPLACEMENTS OF THE UTEEUS. 

and consequently referred to congenital origin. In a large majority, 
however, we may trace the history back to accouchement, The pre- 
disposing causes are enlargements and partial or complete passiveness 
of a part or the whole of the muscular fibres of the uterus. These 
are the conditions in confinement at full term, or abortion or prema- 
ture labor, also enlargement from hydatids, hydronietra, tumors, etc. 
When the uterus is thus enlarged and lax after a greater or less loss 
of its contents, traction on the cord or placenta, or contained tumor, 
or injudicious or accidental pressure on the fundus by the hand of 
some person, or the action of the abdominal muscles thrusting the 
contents of the abdomen downward upon that part of the organ, it 
may be inverted. It is possible, I think, also, that powerful, irregular 
action of the fibres of the uterus ma} r cause the initiation and comple- 
tion of the process of inversion. It is then said to be spontaneous. 
The w T eight of the placenta, or the contraction to expel a polypus, 
may commence inversion, and even complete it. The irregular con- 
tractions that result in inversion may commence before the expulsion 
of the child. After the liquor amnii has been discharged for a long 
time, the uterus contracts to suit the inequalities of the fetal surface, 
the globular shape of the organ being replaced by inequalities in a 
number of places. Much is yet to be learned on this subject. It 
would seem clear from statistics brought forward by Drs. West and 
McClintock that it is exceedingly rare, if it ever occurs, under good 
management of labor cases. It has not been encountered in patients 
confined in the London Maternity Charity, nor the Lying-in Hospi- 
tal of Dublin in 140,000 cases. The student is not to consider from 
this that it is impossible for it to occur in the hands of the ablest of 
accoucheurs. 

Symptoms. 

Usually these are appalling in the extreme. Without warning the 
patient is seized with faintness, coldness of the extremities, sense of 
great prostration, rapid and very feeble pulse, oppression about the 
heart, copious perspiration, hurried breathing, often vomiting, ring- 
ing in the ears, and blindness. Soon these symptoms increase, until 
the patient lies in a profound state of collapse, indifferent to every- 
thing transpiring around her, or throwing herself in every direction 
in paroxysms of agony inexpressible. This condition of collapse is 
not always the result of copious hemorrhage, but seems to be of 
nervous origin, a shock not unlike that caused by severe accidents, 
as falls, strokes, etc. But, generally mingled with this sort of im- 
pression, there is profound exhaustion from loss of blood. From this 
state of collapse the patient may very slowly rally, until she enters a 
tedious and imperfect convalescence- Or, in the cases where the ex- 
haustion from hemorrhage is added to the great depression of the 
shock, the patient may be overwhelmed, and in a hour, or very few 



INVERSION OF THE UTERUS. 545 

hours, her sufferings end in death. Imperfect recovery from the great 
effects of the first shock may enable the patient to live for several days, 
and at last, in five to ten days, die. In case the patient recovers from 
the first symptoms, after some weeks she may regain a fair degree of 
health, and retain it, or even improve, until lactation gives place to 
ovulation, or until this last function supervenes upon the first. The 
first menstrual discharge is preceded by copious mucous evacuation, 
and when the menses begin they are more than ordinarily profuse, 
and generally before they cease amount to prostrating hemorrhage. 
This hemorrhage is repeated monthly, more frequently, or is continu- 
ous, while the leucorrhceal discharges become very profuse. Func- 
tional derangement of other and important organs enters the list of 
morbid impressions; the bowels are constipated, the heart palpitates, 
the stomach cannot digest with its former vigor and completeness, the 
head aches, the eyes become weak; the disposition of the patient 
changes ; the memory fails her ; she is pale, cold, and anaemic ; in 
short, she enters a decadence that is continuous, until, after several 
months, or a few years, she is exhausted and dies. Although this is 
the course usually pursued by cases of inversion, it must be remem- 
bered that there is a class of them in which the patients do not suffer 
even much inconvenience, and their condition is discovered only by 
accident during their life, or on the dissecting-table. 



When the symptoms present themselves so as to awaken suspicion, 
the diagnosis of recent cases may be made out quite clearly, by the 
descent of a tumor into or entirely through the vagina, and the ab- 
sence of the uterine globe above the symphysis pubis. The diagnosis, 
after a few days or weeks have elapsed, and the case becomes chronic, 
is not quite so simple and ready. The tumor is felt in the vagina,, 
and is more sensitive than polypus. It is easily surrounded by the 
fingers, and by introducing two fingers in the vagina to the upper 
end of the tumor, the depression formed by the junction of the vagina 
and uterus may generally be easily surveyed. If this is not entirely 
satisfactory, the sound should be introduced into the vagina before 
the fingers are withdrawn, and, guided by them, be made to sink as 
deeply into this depression as it will go without too much force. If 
the uterus is inverted, the probe will not pass beyond the fingers any 
distance, but if the vaginal tumor be a polypus, the sound will pass 
up at some point some inches above the fingers into the uterine 
cavity. Traction often causes the depression between the inverted 
body and the os to disappear. A polypus, as Reamy has pointed out, 
may often be rotated, while the uterus cannot. The operator may 
test the position of the uterus in another way, by introducing the 

35 



546 DISPLACEMENTS OF THE UTERUS. 

finger high up into the rectum, so that the end may reach above the 
tumor, and retaining it there, he may pass a catheter or sound into 
the bladder, and approximate the two ; if the womb is in place, its 
thickness will be perceived interposed between the two, but if inverted, 
the extremity of the catheter can be brought down upon the finger, 
with nothing but the membranous walls of the bladder and rectum 
intervening. 

Prognosis. 

No more serious complication of labor can occur than inversion of 
the uterus. The danger is great and imminent; in a considerable 
majority of cases proving fatal, the patient dies within a few hours. 
Mr. Crosse says : " In seventy-two out of one hundred and nine fatal 
cases, the patient died within a few hours, eight of the remainder 
within a week, and six more within four weeks; another at five 
months, the result of an operation which had an unsuccessful issue, 
one died at eight months, three at nine months, and the others at 
various periods of from one to twenty years." ( West.) Death in the 
first place, soon after delivery, seems to be the result of rapid exhaus- 
tion of the vital forces by the terrible shock to the nervous system and 
the profuse hemorrhage that often complicates it. Death in subse- 
quent times, however remote in the chronic form, is brought about by 
impairment of the vital functions by the same means, operating more 
slowly, but as surely. The patient dies from exhaustion in both 
forms. Accordingly, we find that while inflammation has something 
to do in affecting the issue in rare instances, those cases in which 
there is no uncommon hemorrhage or leucorrhceal discharge last 
longest, and sometimes do not prove fatal at all, the patient enjoying 
fair health for many years. I know one patient, fifty-six years of age, 
whose uterus was inverted sixteen years ago, and yet remains in that 
condition, as I have verified by examination, who is in the enjoyment 
of as good health as the majority of women of her time of life. 

Treatment. 

The management of recent cases will be the easier the sooner after 
the accident it is commenced. Its reduction is generally successfully 
accomplished within the first hour or two if intelligently attempted. 

It is more difficult as time elapses, but it should never be considered 
impracticable until proper and persevering efforts have been made. 
The first item for consideration and action is to dispose of an attached 
placenta when the uterus has not detached it before, during, or after 
its descent. If the placenta is wholly adherent, its attachment should 
in nowise be interfered with until the uterus is returned to its former 
position; but if it is partially detached, it should be immediately 
separated by gently " peeling " it off with the fingers. This instruc- 



INVERSION OF THE UTERUS. 547 

tion has reference solely to the prevention or lessening the amount of 
hemorrhage. If the placenta is attached throughout, the hemorrhage 
will be trifling ; if partially separated, the condition most likely to be 
accompanied with fatal hemorrhage exists — relaxation of the uterus 
and partial separation of the placenta. It is well known that suffi- 
cient contraction of the uterus will separate the placenta, and when 
not contracted enough to do so, it is in too lax a state for us to desire 
its detachment. If the placenta is partially separated, the completion 
of it by the fingers, as in the case when included in the uterus, will 
enable and stimulate this organ to contraction, and thus to the sup- 
pression of the hemorrhage. I do not think the question of conve- 
nience of return, or the possibility of being foiled in the reduction by 
the continued attachment, should be entertained. The want of con- 
traction enough to throw off the placenta is an evidence of such pro- 
found inertia as to insure easy reduction of the uterus. 

It being decided what course to pursue with the placenta, imme- 
diate efforts should be made to revert. And before beginning these 
efforts, we should remind ourselves of some facts in the case that are 
apt to be lost sight of in the hurry and confusion of such an appall- 
ing occasion. One fact is, that immediately after the occurrence of 
the accident, the uterus is in the same flaccid condition in which it 
was incapable of resisting the action of the cause ; another is, that it 
soon begins to contract, becomes firm, and, consequently, more diffi- 
cult to affect by counter influences; and a third, that the more the 
uterus is stimulated, by handling or otherwise, the sooner and more 
firm the contraction becomes, and, consequently, the greater difficulty 
in reduction. 

No operator has complained to us of the bulk being too great to 
return, but all of the resistance caused by contraction. The experi- 
ence of Dr. Meigs is conclusive on this point. He found that upon 
attempting to reduce the size of the uterus, by squeezing it to expel 
the blood, he caused it to contract, and it became so hard as to resist 
his efforts to push it up within the os ; but as soon as he pressed 
upon the fundus he would depress it, or rather elevate it, until, by 
continuing pressure, he made it ascend first into the body, and 
through it into the neck, and finally up to its proper place. Dr. 
White, of Buffalo, although he did not mention with the same dis- 
tinctness the effects of the two sorts of pressure, was enabled, by in- 
denting first and then following up the vantage, finally to push the 
fundus up the same way through the os and body of the uterus after 
he had in vain tried to reduce it by squeezing, etc. Dr. White's case 
was reduced in this way eight days after delivery. And I must be 
allowed to express the opinion, that it increases the difficulties in 
recent cases of inversion to try to lessen the bulk of the uterus. A 



548 DISPLACEMENTS OF THE UTERUS. 

great bulk indicates a flabby, reducible state, and is favorable to 
success instead of otherwise. Do not squeeze the uterus to lessen its 
size in these cases. 

The two cases I have referred to, of Drs. White and Meigs, so in- 
telligently and deliberately observed, and so clearly described, furnish 
us with more intelligible means of arriving at correct ideas of the 
steps by which inversion of the uterus is reversed, than any I am able 
to find on record. They both concur in showing the usefulness of one 
hand in the vagina to steady the uterus, and direct the force applied 
to the fundus by the other hand, and the injurious effects of compress- 
ing the body of the organ. The most appropriate mode of operating 
in recent inversion, therefore, is to introduce the left hand into the 
vagina behind the uterus, while with the fingers of the right the fundus 
is indented, and gently, but steadily and perseveringly, reverted en- 
tirely above the os and cervix, until it assumes the globular shape 
and proper position above the symphysis. If the fingers of the right 
hand cannot be used to advantage, or are too weak to accomplish the 
desired elevation, we may use a large elastic rectum bougie, an instru- 
ment resorted to by Dr. White, or one by Dr. Beers, shaped like the 
end of a walking-cane, with a round smooth head upon a staff. The 
indentation and elevation may be more efficiently effected by this 
latter instrument, perhaps. 

The fact cannot be too forcibly impressed upon our minds, in un- 
dertaking this operation, that gentle firmness is the proper expression 
for the force to be employed. Perseverance, instead of violence, is 
both more certain, successful, and secure, in overcoming the resist- 
ance of muscular fibre anywhere. This is especially true with the 
uterus, the strongest muscle in the body. As nearly as may be, we 
should act in the absence of uterine contractions. During and after 
the time we are attempting the return of the organ, the strength of 
the patient must be supported by stimulants, tonics,, and nutrients. 
Brandy will, perhaps, serve best to restore the circulation and heat ; 
it may be aided by the use of the aromatic spirits of ammonia and 
laudanum. In addition to the stimulant and supporting influence 
which laudanum exerts, it allays the irritable condition, so frequently 
present, of the stomach, the uterus, etc. After the urgency of the 
symptoms has passed by, the tincture of iron, quinia, beef essence, 
and nutritious diet generally, will be necessary to restore the im- 
paired condition of the vital energies. The energy with which the 
stimulants are to be urged during the shock must be regulated by 
the urgency of the danger. Large doses of brandy, laudanum, and 
spirits of ammonia will not only be borne, but often be called for to 
meet the symptoms. 



INVERSION OF THE UTERUS. 549 



The Treatment of the Chronic Form 

Is palliative and curative. The palliative is for the purpose, as far 
as possible, to check the drain which is so constantly exhausting the 
patient, to support the system as well as we can, and to use any other 
means suggested by the circumstances for the relief of distressing 
symptoms. 

The hemorrhage is from the mucous membrane of the uterus, its 
outer surface as it lies in the vagina, as also the profuse mucous dis- 
charge. I think much may be done to moderate, if not stop, these 
evacuations by astringents introduced into the vagina, so as to sur- 
round and lie in contact with the uterus. Pledgets of lint, saturated 
with the persul. of iron, passed up into the vagina, and allowed to 
remain on the bleeding surface of the uterus until the bleeding ceases, 
will be of great service. The tinct. ferri chlorid. on lint is an excellent 
application for the same purpose. Other astringents may be tried in 
the same manner. If these should fail, the vagina may be tamponed 
fully with cotton, dipped in astringents or not as the physician may 
think best. Severe paroxysms of hemorrhage should be carefully 
treated in this way until they terminate, it being desirable to save as 
much blood as possible. It is not necessary to suggest to the intelli- 
gent reader the necessity of rest in the horizontal position. Between 
these paroxysms the patient should use astringent injections of con- 
centrated strength, saturated solutions of alum, acetate of lead, tannin, 
etc., with a view to condense the mucous membrane, and render it 
less vascular, and in this way abate the urgency of the losses. The 
tinct. ferri chl., one part to four of water, twice or thrice a day, will 
have an efficient astringent effect upon the uterus. When the organ 
extends through the vulva, it is irritated by contact with the limbs 
and clothing, and it is very desirable to return it into the vagina, and 
keep it within that cavity. The gum-elastic air-pessary, supported 
by a T bandage, will keep it in the vagina, and may render it more 
easy of a radical cure, by reduction or reversion. I would urge the 
attendant to personal attention to this treatment, to such an extent, 
at least, as is necessary to have it efficiently tried. Very few patients 
have the intelligence to appreciate the importance of it, or to know 
when proper trial of it has been made. 

The radical treatment has for its objects either a restoration of the 
organ or its amputation and removal. So far as we can judge, 
although both operations are attended with danger, that of amputa- 
tion the more. And I think it clearly the duty of the practitioner, 
when driven to a choice between the two, to give preference to at- 
tempts at restoration. We have not only greater safety as an argu- 
ment in favor of it, but successful restoration reinstates the patient 
in all her sexual capacities, while amputation, if not diastrous in 



550 DISPLACEMENTS OF THE UTERUS. 

other respects, renders her forever sexually neuter. It is to be hoped 
that before long the operation of amputation will be regarded as un- 
justifiable, because of the certainty of restoration. Great improve- 
ment in our means and the mode of effecting this must be made, 
however, before this conclusion can be reached. There is no longer 
room for doubting that restoration of the inverted uterus occurs spon- 
taneously, I think it is proven Jby the case of Dr. Hatch, published 
in Dr. Meigs's Obstetrics. The case of Madame Beauchardat, pub- 
lished by Baudelocque, is also, I think, conclusive on the point of 
restoration. Other cases, less clearly and circumstantially reported, 
may be found scattered through medical literature for the last cen- 
tury. There are two methods, if they may be so denominated, that 
have been successful in reducing chronic inversion of the uterus. 
Two representative cases are published in the American Journal of 
Medical Sciences for July, 1858 ; one by Professor White, of Buffalo (it 
was his second case), and one by Dr. Tyler Smith, of London. It will 
be observed, by examining the reports of these cases, that the restora- 
tion began by the cervix passing through the os uteri first, then the 
body, and finally the fundus. This is different from what I think is 
the common mode of restoration in recent cases. The operation for 
reversion in Dr. White's second case was completed, we are led to 
suppose, in something more than an hour, and at one sitting. The 
uterus had been inverted five months. Dr. White operated by in- 
troducing the hand into the vagina while the patient was in a state 
of anaesthesia from chloroform, squeezing the uterus so as to lessen 
the size as much as possible, and at the same time pressing the organ 
upwards by means of the large rectum bougie. Success followed a 
somewhat protracted manipulation. The uterus was restored by the 
lips of the os uteri beginning to fold outward, and the neck to pass 
up through this opening, next the body, and afterwards the fundus. 
There is nothing in this case said about the fundus being indented 
from beginning to end. This is no more than might be expected by 
considering the anatomical circumstances. The fundus and corpus 
uteri are firmer and more solid than the cervix, and hence less likely 
to yield to the same amount of force. The force applied to the fundus, 
when the organ is strongly pressed upward, acts more efficiently upon 
the cervix than any other part, from the fact that the vagina, attached 
all around the mouth, has not merely the effect of resisting the up- 
ward pressure of the uterus, but, being upon the outer surface, it ini- 
tiates and keeps up the funnel-shape expansion of the os necessary to 
permit the other parts to pass through it, as well as to draw it down 
over the part entering it from below. 

I believe that, in some respects, this is the best manner of operating 
for immediate restoration, yet one thing done seems to me to be super- 
fluous, if not mischievous, viz., the squeezing the uterus. Dr. Sims 



INVERSION OF THE UTERUS. 



551 



recommends that the uterus be supported by one hand above the 
pubis to prevent too great extension upon the vagina. While the 
uterus is being pushed up from below, the cup-shaped cavity formed 
by the inverted cervix may be felt if we forcibly press the ringers 
down into the pelvis from above over the pubis. This manipulation 
affords us valuable aid in forming our diagnosis, while it gives the 
opportunity of assisting in the reversion. The great thing to be gained 
is the commencement. After the neck is one-half reverted the restora- 
tion proceeds with more rapidity and ease than before until complete. 
A better instrument than the bougie used by Dr. White would be a 
cup on a strong handle, large enough to safely lodge the fundus of the 
uterus. Dr. White now uses what he calls the repositor. The figure 



Fig. 271. 



Fig. 272. 




White's Repositor. 

shows its action with sufficient clearness to require no extended ex- 
planation of its use. The steps in the operation for immediate restora- 
tion are, first, to introduce the hand into the vagina, and, embracing 
the uterus with it, hold the organ steady, with the fundus and cervix 
nearly parallel with the axis of the superior strait; second, place the 
fundus of the uterus in the cup of the instrument held by the other 
hand, and then press gently upward, increasing the firmness of it 
until it is as great as the parts will bear without violence, and con- 
tinuing it with such force until the parts yield and pass up. The 
time required may be considerable, and it is an object to continue it 
for a long time, increasing the pressure so slowly as not to be per- 
ceived, except by comparing it at considerable intervals. The patient 
should be under the influence of chloroform to insensibility, and 



552 DISPLACEMENTS OF THE UTERUS. 

placed on her back, with the limbs widely separated across the bed, 
and with the hips very near it ; or, what would be better, an operating 
table of convenient height, about two feet wide and five long. Greater 
facility would be afforded for attendants by such a table. The sur- 
geon should kneel or seat himself in front of the patient, so as to have 
free use of both hands and perfect command of the parts. 

The second mode of restoring the inverted uterus, as practiced by 
Dr. Tyler Smith, is to apply the force so gradually as to require 
several days for the completion of it. The means used were, first, the 
frequent introduction — I think twice a day — of the hand into the 
vagina to squeeze the uterus ; and, second, to keep a gum-elastic air- 
bag distended in the vagina, which constantly pressed the fundus 
upward, certainly, however, with no great force. He succeeded in 
restoring a uterus that had been inverted for fifteen years. With 
proper apparatus I should very much prefer this gradual method, as 
requiring less violence, being less hazardous, and perhaps less painful. 

A sufficient number of cases have been successfully treated by this 
means to justify giving it a fair trial. Having succeeded in three 
cases in reducing with the elastic bag, I am more favorably impressed 
with its efficiency than Dr. White seems to be. The reduction was 
effected in from five to eight days, without giving the patient pain 
enough to interfere with her sleep, or causing her any serious incon- 
venience. Each day showed advances ; the first, relaxation of the 
rigid neck ; the next, shortening of the displaced uterus ; and each 
day after exhibited gradual improvement until the restoration was 
found to be complete. I am convinced that in many, if not most, of 
the simple cases of chronic inversion the reposition may be accom- 
plished by this method, and I would certainly try it before resorting 
to the more hazardous and more painful plan of Dr. White. Success 
with the elastic bag, however, requires a careful study of each case, 
and a watchful adaptation of the means. The kind of instrument is 
of much importance. The best shape, perhaps, is quadrilateral. It 
should be strong enough to bear considerable pressure without mate- 
rially altering its shape, and furnished with a tube and very tight 
stopcock. The instrument should be distended with water instead 
of air, as there are few that will not permit air to escape in greater or 
less quantities. The chances of success will be increased by a firm 
and well-shaped perineum to support the pressure, and by its own 
elasticity adding to the efficiency of the instrument. When the peri- 
neum is deficient, we may compensate it by well-adjusted mechanical 
support. The more firm the tissues of the vagina the better (Fig. 273). 

The instrument should be introduced in an empty condition, and 
placed well back in the vagina, and the water forced into it until 
moderately distended. We must then carefully examine the relation- 
ship between it and the uterus, and see that the latter is pressed up- 



INVERSION OF THE UTERUS. 553 

ward in the direction of the axis of the superior strait. If this is not 
the case, we may be able to place the uterus in the right position by 
moving it with the finger. If this cannot be done, the bags should 
be emptied and changed until right. If the shape of the instrument 
is not properly adapted to the vagina, it should be replaced by another. 
By exercising due care in selecting and adjusting the instrument, we 
shall be able to get the force exerted in the right direction. When 
satisfied that the instrument is properly adjusted, we should inject 
water into it, and distend it as much as the patient can bear without 
decided pain. It will not be necessary to remove it more than once 
in twenty-four hours, but it ought to be examined in reference to the 
degree of distension, and if it should continue tense, and the patient 
feels no more discomfort from it, we ought to inject more water until 
the patient experiences slight uneasiness from the pressure. Once in 
twenty-four hours the water may be allowed to escape, and the instru- 
ments be removed, the vagina cleansed, and the parts thoroughly 
examined. If we are producing any impression on the rigid cervix, 
the relaxation will be perceptible by the facility with which the uterus 
will move upward. The instrument should be carefully readjusted 
and again distended. On the second removal of the bag I think, 
usually, we may expect to discover decided progress in the process 
of restoration. I do not believe it judicious to manipulate and squeeze 
the uterus, with a view to lessen the blood in it, every time we remove 
the elastic bag, and would sedulously abstain from anything of the 
kind, believing that the reaction after the withdrawal of the hand 
would engorge the vessels of the organ. The daily removal of the in- 
strument, cleansing of the vagina, and readjustment must be continued 
until the uterus resumes its proper position, or until we find we can- 
not succeed by this plan. Judging from my own observation, and the 
cases I have seen recorded, I should expect success to follow between 
the fifth and the eighth days. But efforts may be continued much 
longer than this, if necessary. As soon as the fundus has passed into 
the cervix, it will spontaneously resume its proper position, because 
the resistance to its doing so is removed ; but if this should not occur, 
a rectal bougie maybe placed against it and sufficient pressure exerted 
to rectify it completely. 

The pressure of this elastic bag when properly managed is just the 
kind desired, and the degree may be made very considerable. When 
the bag is of the right size and form, the uterus is pressed upward in 
such a manner as to place the vaginal attachments upon the stretch, 
and cause them to draw open the cervical cavity, and this tension is 
increased by the dilatation of the upper portion of the vagina in every 
direction. It thus acts as a dilator as well as repositor. And although 
the degree of pressure upward is not so great as may be made by the 
repositor of Dr. White, or by the hand, its steadiness of action, and 



554 DISPLACEMENTS OF THE UTERUS. 

the great length of time it may be continued, more than compensate 
in the end for its lack of violent force. We all are acquainted with 
the efficiency of moderate but long-continued traction upon fibrous 
tissue, in cases of long-standing dislocation. 

I will here present a case which has recently come under my ob- 
servation : 

December 24th, 1878. — Mrs. M., Irish, aged twenty-six years, was 
brought to me with inversion of the uterus, which had taken place at 
the time of her first labor, fourteen months before. I obtained a very 
imperfect history of the case, but so far as I could learn nothing un- 
usual occurred during pregnancy, and when the labor began the 
patient was in the enjoyment of robust health. The first and second 
stages of labor were normal, and together lasted six hours. During 
the third stage hemorrhage was alarming, and the succeeding pros- 
tration very great. The patient could give no intelligent account of 
the mode of delivering the placenta, or of the duration of the third 
stage. The only recollection of it was that she suffered from great 
pain and weakness. The accident was not discovered at the time, 
and when, after the lapse of some weeks, the attention of the prac- 
titioner was called to the unusual condition of the contents of the 
vagina, he said : "She must have a polypus or something else." He 
either was not aware of what had occurred or did not wish to have 
the true condition known. 

Astringent injections were used and stimulants and tonics given. 

The patient gradually rallied, and during the first year was seen by 
a number of physicians, and many opinions were expressed and 
methods of cure tried. No benefit resulting from treatment, she came 
under the care of Dr. White, of Bloomington, who recognized the 
true condition of the patient, and made a very judicious and prolonged 
effort to reduce the uterus by the forcible method and failed. He 
then advised her to visit me for further treatment. 

W^hen she arrived she was very anaemic and exhausted. She was 
constantly discharging blood and mucus, and at the time of her 
menses flowed profusely. There was great tenderness and sensitive- 
ness of the vagina, uterus, and lower portion of the abdomen. The 
pulse was weak and about one hundred to the minute. She had a 
poor appetite and was obstinately constipated. 

An examination confirmed the diagnosis of Dr. White. The vagina 
was very capacious, and depending from its roof was a small, very 
firm uterus. The involution seemed to have been carried beyond the 
ordinary degree. It was in a state of hyper-involution. It was com- 
pletely inverted. The labia could be felt forming a thin border, com- 
pletely surrounding the cervix, with the likeness of a fringe, the edge 
pointing upwards. The uterus was so firm and condensed that it 
resisted every effort to elevate it. It could be drawn down somewhat. 



INVERSION OF THE UTERUS. 



555 



bringing with it a pouch of the upper wall of the vagina. There was 
considerable sensitiveness of the iliac and hypogastric regions, but no 
tumefactions, induration, or other evidence of the products of inflam- 
mation. A mild cathartic was administered, followed by the tincture 
of iron and quinine, and on Christmas day the treatment for reduc- 
tion was commenced. An elastic bag, four inches long, and when 
distended three inches in diameter, with a tube attached, was selected 
as the main instrument. When collapsed this bag presented a quad- 
rilateral shape, larger in the centre and slowly tapering towards the 
ends. I selected a sac of this shape because it filled the vagina from 
the vulva to the bottom of the fornix, and when introduced one of 
the faces reached the fundus in such a manner that the organ would 

Fig. 273. 




Reduction of Inversion by the Elastic Bag. 

not easily slide over its sides. As the bag was slowly distended the 
fundus produced a depression in which it was firmly retained when 
the sac was filled. 

I introduced this bag, while empty, so that it lay on the posterior 
wall of the vagina, and carefully adjusted the dependent fundus so 
that the body was in a line with the axis of the superior strait. 
Water was slowly injected until the distension produced a sense of 
discomfort. The distension was kept up for twenty-four hours, when 
the water was permitted to flow away. The instrument was removed 
and cleansed, and again replaced and filled. The first time it was 
removed an evident softening of the cervix was noticeable, and the 
body could be pressed slightly into it. From day to day the softening 



55*3 DISPLACEMENTS OF THE UTERUS. 

and dilatation became greater, and upon the removal of the instru- 
ment advance was ascertainable. Upon removing the bag, on the 
seventh day, I found that the uterus was in a state of complete inver- 
sion, and all progress seemingly lost. With the finger, however, I 
could easily press the fundus entirely into the dilated cervix, thus 
assuring myself that the work of reduction was almost complete. A 
more careful adjustment and careful distension of the bag were 
effected, and on the removal of the instrument on the eighth day it 
- found that the fundus had mounted to its normal position. The 
sound was introduced two and a half inches. This patient improved 
in strength and became more comfortable from the commencement of 
the treatment to the end. After the first three days she was up during 
a part of the day, and on the seventh and eighth was about her room, 
and, in addition to keeping her room in order, gave hex child all the 
attention it needed. 

I have no doubt that she was perfectly truthful in her assertion 
that the treatment gave her no inconvenience except at the time and 
for a few moments each time after the adjustment of the instrument. 
There was no time when I felt the least uneasiness about the effects 
of the pressure, or was under the necessity of giving anodynes for the 
relief of pain ; nor did the presence of the instrument prevent the free 
and comfortable evacuation of bladder and rectum. In fact, the 
patient improved from the time she was placed under treatment. 

Notwithstanding the important improvements of Dr. -J. P. White, 
who deserves more credit for his success and teaching in inversion 
than any other man, and Dr. Tyler Smith's success in the use of the 
gum-elastic bag, there will yet remain cases in which the uterus can- 
not be restored to its natural position and relations. Inversion, com- 
plicated with several fibrous tumors of the body or fundus, will resist 
ordinary methods of reduction, and. no doubt, cases in which the 
causes of difficulty cannot be precisely discovered will occasionally 
be found unmanageable. What shall be done with such ? The neces- 
sity for any operation that involves the life of a patient, already in 
great danger, should be clearly determined by the circumstances of 
the case and with ample counsel. If the patient's health is growing 
worse and her strength being exhausted by great discharges or per- 
sistent inflammation, relief should be attempted at all hazard. If, 
however, the woman is enjoying fair health, or if the symptoms that 
usually harass her after the accident of inversion are improving, any 
operative procedure beyond efforts at reduction, is not justifiable. 

In cases where restoration is proven to be impossible by proper, 
prolonged, and repeated efforts, or the uteru- is b : enlarge 1 by morbid 
growths as to make it obviously useless to try reduction, and the con- 
ditions demand relief, amputation is the last resort, In a rfa 
found in the American Journal August, 1868, translated 



INVERSION OF THE UTERUS. 557 

from the German, we have ^fifty-eight cases reported of amputation of 
the inverted uterus; eighteen terminated fatally, forty recovered. 
This is a large mortality, but probably the fatality will become pro- 
portionately less as all the conditions of the operations are improved. 
The methods of amputation now practiced are essentially three: 

1. Ligating and allowing the ligature to remain until it cuts 
through. 

2. Ligating to prevent hemorrhage, and then amputating below the 
ligature with the knife, scissors, or ecraseur. 

3. Passing the ecraseur or galvano-cautery wire through the sub- 
stance of the cervix wuthout ligating. 

The ligature, when properly applied, effectually prevents hemor- 
rhage, but it is very likely to cause inflammation, also a very formid- 
able occurrence, and one which is the frequent cause of death. Or if 
it remains long enough to cause sloughing, even of the amputated 
stump, there may arise toxaemia, resulting from the absorption of the 
putrid substance. The ecraseur avoids this latter difficulty, but I 
should fear it would be an insecure guarantee against hemorrhage in 
all cases. Dr. Thomas Hay, of Philadelphia, reports, in the Medical 
and Surgical Reporter, December 2d, 1871, a case in which amputation 
was successfully performed by the ecraseur alone. Dr. McClintock, of 
Dublin, applied the ligature for forty-eight hours, and then removed 
the uterus by amputating with the ecraseur in the groove formed by 
the ligature. Practical demonstration is the only reliable guide in 
important operations ; we are not supplied, however, with enough ex- 
amples of success by any one procedure to justify us in making a posi- 
tive choice between them. 

It will not be difficult to get access to the cervix for the purpose of 
applying the ligature or amputating. This may be done by drawing 
the organ down to the vulva with vulsellum forceps. 

The galvano-cautery is better than all the above methods of ampu- 
tation. 

The wire applied as an ecraseur, heated to a dull red color, and 
drawn slowly through the cervix, will do away with the dangers of 
hemorrhage, and leave no sloughing surface from which sepsis may be 
generated. 



CHAPTEE XXXIV. 

DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

The uterus is very much hypertrophied by the processes of gesta- 
tion, so that after its contents are expelled by labor, the organ weighs 
from one and a half to two pounds. An atrophizing process, called 
involution, serves to reduce the organ to its original conditions in size 
and weight. 

Involution is a physiological change, as much so as evolution; but 
not unfrequently disease invades the tissues and renders it abortive : 
1. Causing it to be temporarily " delayed ; " 2. To fall short of comple- 
tion after it has been commenced ; or, 3. To proceed entirely beyond 
the limits compatible with the healthy functions of the uterus, reducing 
it below its usual weight and size. 

I mean by the term " delayed involution " to designate a condition 
of the uterus in which this process does not begin for a number of 
days — from ten to fourteen — after parturition. 

The contractions which immediately succeed and continue after 
labor, by interrupting the circulation in the substance of the uterus, 
initiate that process, and by the end of a fortnight it is half finished. 
Should these contractions be rendered inefficient, involution is at a 
stand, the uterus remains large, the circulation too great for safety to 
the patient, and sufficient to keep up the nutrition in the muscular 
fibres, which are still capable of a good degree of energetic action. 
For a number of days the uterus is felt to be as large as a child's head 
above the pubis, and not very firm. 

Causes. 

The most common cause of this delay is inflammation attacking the 
substance of the uterine walls. The inflammation may be acute, and 
the patient's suffering such as to demand attention, or so slight as to 
pass without much notice. Cases of puerperal metritis, for a week or 
ten days immediately succeeding delivery, not unfrequently present 
this enlarged condition of the organ. 

Another cause which probably operates to prevent involution is 
atony of the uterine muscular fibres. The contractions are feeble, 
and so inefficient as to delay for a long time, and render very slow, 
the early stages of involution. Too early assumption of the erect 
posture and undue exercise on foot, keeping the bloodvessels of the 
uterus distended unduly, and thus overcoming the muscular contrac- 
tion, are not unfrequently the causes of delayed involution. 



SYMPTOMS — PKOGNOSIS— TREATMENT. 559 

Symptoms. 

The symptoms of delayed involution, separate from the inflamma- 
tion, are not always very well marked. Weight, heat, and aching in 
the back are the most frequent, especially if inflammation is the cause. 
There is always great danger, however, of a very alarming symptom 
w T hile this state of the uterus exists, and that is flooding. Where the 
delayed involution is dependent on atony of the muscular fibres, hem- 
orrhage is sure to take place if the patient exerts herself considerably. 
As the first indication of any seriously wrong condition of the uterus, 
the patient is suddenly seized with copious hemorrhage, which sub- 
sides under the influence of rest, cold, and astringents, but suddenly 
and unexpectedly recurs without adequate cause. When suspected, 
the diagnosis is not difficult by an examination with one finger of the 
right hand per vaginam, while with the left hand pressure is made 
above the pubis. The uterus, thus examined, is found to be as large 
as immediately after labor is ended. 

The soft, uncertain condition of the uterine globe will not always 
enable us to discover it by placing a hand upon the lower part of the 
abdomen alone, but by including the organ between the two there will 
be no danger of mistake. If the organ retains sufficient firmness to 
be easily distinguished above the pubis by the single hand, there will 
be but little danger of hemorrhage. The local distress will then be 
the only indication of the necessity of a diagnostic examination, when 
the greatly enlarged condition will be easily detected by the examina- 
tion above directed. The fingers may be easily made to enter the 
mouth of the organ and move the whole mass, while the hand above 
will easily recognize the movement, or the hand above may be made 
to press it down upon the fingers below. 

Prognosis. 

There is imminent danger of serious, if not fatal, hemorrhage. I 
have known as many as two cases of sudden fatality from flooding 
after the seventh day from the time of labor. It is always a serious 
condition, and should be watched diligently and treated efficiently. 
Even in cases where the delay is caused by acute inflammation great 
hemorrhage may take place, although not so likely as when caused by 
muscular atony alone. If the delay is for a very considerable length 
of time, the involution is pretty sure not to be completed, but the uterus 
remains in a state of subinvolution for an indefinite time. Very often 
the causes which effect delays continue to act, and finally produce 
subinvolution. 

Treatment. 

The treatment depends upon the causing conditions. If there is 
inflammation of the uterus the antiphlogistic measures necessary to 



560 DISEASED DEVIATIONS OF INVOIXTI02s OF THE UTEEUS. 

combat it are demanded, with counter-irritation, fomentations, etc. 
Should atony, unattended with inflammation, exist, ergot in large 
doses is demanded imperatively until ergotism is manifest 

I usually give 3ss. pulv. seeale corn, in infusion, every half hour 
until there are contractions. When this is done the effect of the 
drug may so subside that it will be necessary to administer it again in 
twelve or twenty-four hours, until all disposition to relax has passed 
away. When atony and the inflammatory condition coexist, which 
may be known by the tenderness, fever, and hemorrhage occurring to- 
gether, the ergot and other treatment should be combined. Hemor- 
rhage is not likely to come on until after the inflammation has pretty 
well subsided, and aids usually in removing the last of it. 

I subjoin two cases as representatives of the two conditions of the 
uterus, and the mode of treating them : 

Case I. This case was furnished me by Dr. S. Wickersham, of this 
city. He was called to see Mrs. E., an Irishwoman, aged twenty-eight, 
in her fourth labor. May 7th. 1S63. 4 o'clock p.m. She had been in 
labor, attended by a midwife, for the most of the day. At 1 o'clock 
A.M. of the 8th, pains had entirely ceased, from atony or exhaustion 
of the uterus. Constitutional symptoms began to -how the necessity 
for relief. The forceps were used, and the child was delivered. The 
placenta was delivered in due time without difficulty, and the uterus 
contracted well. Hemorrhage not more than usual. The pulse was 
unusually frequent at and after the time of delivery. The labor was 
followed in two days with puerperal fever, in which the uterus and 
peritoneum were both involved. Up to the 20th she had improved 
very much, so as to be considered by the doctor as convalescent. In 
the early part of the day sudden and violent hemorrhage prostrated 
the patient to what was at the time considered a moribund condition 
but by active stimulation and external warmth to her cold extremi- 
ties she rallied, and appeared to be slowly recovering. At 6 o'clock 
p.m. on the 24th. the hemorrhage returned with "terrible violence," 
and she was thought again to be dying. Notwithstanding the most 
energetic use of stimulants she could hardly rally from this last 
attack. On the 26th. in consultation with Dr. Wickersham. I found 
the patient so prostrated as to leave but little hope of her recovery. 
Suspecting that the uterus was in a state similar to what is found 
immediately after delivery, I insisted upon making an examination, 
which was resisted by the patient and friends. Through the kind 

severance of Dr. Wickersham I was permitted to do so. The 
uterus was so flaccid that I could not discover it above the pubis 
until after introducing the finger into the vagina and moving it about. 
when the fundus could be felt as high as the umbilicus, with the 
regular globular form. The mouth and cervix were large and flabby. 
and easily admitted two fingers, After this examination the indica- 



TREATMENT. 561 

tion seemed plain. Large doses of ergot were given in addition to 
the stimulating and supporting treatment. Hemorrhage was very- 
slight on the morning of the 27th. She continued to improve slowly 
until the 9th of June. At 5 o'clock a.m. the hemorrhage returned, 
and lasted until 10 o'clock a.m., but in so moderate a degree as to 
produce but little effect upon the patient. I was not in attendance 
after the first consultation, and could not trace the steps of condensa- 
tion, but after the 9th of June the hemorrhage did not recur. 

It will be seen that on the twelfth day after confinement dangerous 
hemorrhage took place ; that it again returned on the sixteenth day 
after delivery to a very alarming extent ; and that after the liberal 
use of ergot the hemorrhage returned but slightly. It should be 
noted, also, that the cessation of the hemorrhage was sudden, and 
probably resulted from faintness, and that it returned as soon as the 
arterial reaction amounted to any considerable degree. The faint- 
ness, doubtless, was the cause of stoppage in both attacks before ergot 
was given, but the hemorrhage was effectually checked by contrac- 
tions produced by the ergot. 

Case II. Mrs. E. is the mother of nine children. She is thirty- 
three years of age, and a German Jewess. Of robust, almost athletic 
make and habits, she always enjoys excellent health. In the last 
three confinements she has almost lost her life from loss of blood, 
both before and after the delivery of the placenta. I attended her in 
the eighth labor, the last before this one. There was nothing peculiar 
in it until after the child was delivered, the labor having lasted but 
about four hours. The pains were ordinarily vigorous and propul- 
sive. The liquor amnii was not evacuated until ten minutes before 
the head was distending the labia. After the child was expelled the 
uterus did not contract thoroughly. It seemed large and rather soft. 
This state lasted for half an hour, when a feeble contraction detached 
but did not expel the placenta. From this time hemorrhage became 
excessive. I waited for half an hour — using friction, kneading, and, 
pressure over the uterus, with application of ice to the vulva — for 
contraction of the uterus and expulsion of the placenta, but although 
there were occasional pains, they were so feeble as to produce no 
effect upon the hemorrhage. About this time the ergot I had sent for 
arrived, and I gave immediately 3ss. in a little wine and water. 
Fearing the prostration which was rapidly coming over the patient, I 
introduced my hand into the uterus, grasped the placenta, and irri- 
tated the organ by moving the whole around in it. This brought on 
contractions enough to expel my hand and placenta, and deluge the 
bed with coagula and fluid blood. Very soon the ergot began to act, 
and the hemorrhage ceased. I give this description of her eighth 
labor to show her predisposition to inertia uterina. As the ninth 
labor approached, I determined I would administer the ergot as soon 

36 



562 SUBINVOLUTION OF THE UTERUS. 

as the parts were well dilated, and the head began to pass the os 
uteri. I was sent for at 8 o'clock p.m., June 30th, 1864, to attend her. 
I found the pains active and the os uteri fully dilated, and the mem- 
branes distending the labia. I at once gave her ergot 3ss. in infusion, 
making her swallow the ergot as well as the water. This was repeated 
in half an hour. By this time ergotism was fairly established. In 
three-quarters of an hour from the time I arrived the child was born, 
and in a few minutes the placenta was expelled from the uterus into 
the vagina whence it was removed. No hemorrhage followed. The 
uterus was well contracted. I considered her condition very favor- 
able, and at the end of another hour took my leave. Her condition 
for the first forty-eight hours was in no respect unusual, except that 
the lochial discharge was rather free. From this time I saw but little 
of her until the 10th of July. I returned from the country at 5 o'clock 
p.m., and found she had been flooding since early in the morning, not 
very greatly, but sufficient to begin to produce faintness. The uterus 
could be felt above the symphysis pubis as large as a child's head, 
and not very hard. I ordered cold to the pubis, and twenty drops of 
aromatic sul. acid in some water every four hours, expecting soon to 
have the hemorrhage checked ; but to my surprise, at 8 o'clock on the 
11th, the hemorrhage still continued, being but slightly moderated by 
the means used. I now ordered two teaspoonfuls of vin. ergoti every 
half hour until the hemorrhage ceased. But the nurse said that the 
" second dose put her in so much pain and caused such large clots of 
blood to come from her that she dare not give it again." The hemor- 
rhage ceased entirely from this time until the afternoon of the 13th, 
when it returned with considerable violence. The ergot was again 
given, and from this time forward the patient had a favorable con- 
valescence, and is now in the enjoyment of good health. 

Subinvolution of the Uterus. 

To understand subinvolution in its principal bearings it will be 
necessary to discuss more at length the subject of involution itself. 
I think that involution of menstruation plays a much more important 
part in the structural diseases of the uterus than we have been inclined 
to attribute to it. It will not be considered irrelevant, therefore, to 
take a glance at the subject, as involution presents itself in menstrua- 
tion as well as in pregnancy. 

In the healthy uterus, what may be called trophic changes are con- 
stantly going on, from the beginning of menstruation to the meno- 
pause. The circulation of the uterus is increased in quantity from the 
cessation of one menstrual crisis to the beginning of the next. During 
the days of the flow the afflux of blood subsides to the lowest 
amount. 



SUBINVOLUTION OF THE UTERUS. 563 

From the cessation of the monthly flow there is an increase of solid 
tissue in the uterus until the beginning of the next menstrual flow, 
during which time there is involution or an elimination of solid tissue, 
notably the mucous membrane of the cavity. 

These processes of afflux of blood and accretion of tissue may be, 
and often are, prolonged, and pass into what is known as congestion 
of the uterus. 

When this round of monthly changes is interrupted by pregnancy, 
processes similar in character on a much larger scale are accomplished. 
The afflux of blood and increment of tissue do not attain their maxi- 
mum until the end of gestation. The contents of the uterus are ex- 
pelled, and then begin the changes called involution, the object of 
which is the elimination of the superfluous circulation and solid 
tissues, until the uterus returns to its menstrual status. 

The prolongation or arrest of this is subinvolution. 

Post partum involution is no doubt initiated, if it is not completed, 
through the agency of muscular contractions. The large fibres which 
have been strong enough to expel the foetus, placenta, and membranes, 
continue to contract, and in doing so compress the vessels, and thus 
cut off at once a large quantity of the blood circulating in the uterus. 
As a result of this some of the fibres are deficiently supplied with 
nutritive elements, and undergo fatty degeneration. The granular 
fatty material is absorbed and the general bulk of the organ dimin- 
ished. Further contraction is thus rendered possible, when more 
fibres disappear in the same way until the process of involution is 
finished. The length of time required is, I think, much longer than 
is generally supposed, seldom in one month, often not in three months, 
and sometimes morbid causes prevent it from ever being accomplished. 
The uterus then remains more vascular and bulky than normal, or is 
in a state of subinvolution. 

In both post-menstrual and post-partum subinvolution this simple 
vascular condition does not continue for any great length of time. 
Hyperemia is often a mischievous condition, and sooner or later 
causes changes in the organization of the viscus in which it exists. 
In subinvolution there is at first hyperemia, with hypertrophy of the 
fibrous, vascular, and nervous tissues. These solid portions of the 
organ degenerate, not into a fatty substance that may be absorbed, 
but into fibrous tissue of a low organization. 

Either as the effect of exudation from the capillaries, or the slow 
absorption of the more vitalized molecules of the muscular fibres, or 
both, there comes to be an undue amount of connective tissue. The 
transition from the more muscular and highly vitalized state of the 
uterus to this one of induration may be accomplished in a few months, 
or it may require the lapse of years. When it is complete, many of 
the symptoms that indicated the state of recent subinvolution are re- 



564 SUBINVOLUTION OF THE UTERUS. 

placed by others of a different kind ; especially do the bloody dis- 
charges from the uterus become less than normal. 

Subinvolution is a term, then, which embraces different pathological 
conditions; or, perhaps, it would be expressing the facts better to 
say that several distinct pathological conditions of the uterus result 
from subinvolution. This last statement *will apply equally to men- 
strual subinvolution as to the post-partum. 

We ought not to lose sight of the fact that all the physiological and 
some of the pathological changes occurring in the uterus are to a 
great extent coincidental with, if not the consequences of, the changes 
going on in the ovaries, — the organs that dominate the whole genital 
system. 

During ovulation the menstrual hypertrophy takes place; at the 
time of the discharge of the ovum menstrual involution occurs. 
During the development of the ovum in the uterus, ovarian hyper- 
trophy is going on ; at the time of the expulsion of the ovum the pro- 
cesses of involution begin. 

It is quite probable that after the ovum is inclosed in the uterus 
and gestation established, the uterus is prompted by ovarian influence 
to the enormous physiological and anatomical changes which go for- 
ward in it, up to the perfection of fetal life, and afterward govern the 
processes of labor and involution. It is certain that the ovaries do 
not return to the condition in which they were, before conception, 
until pregnancy has terminated, nor in fact during several months of 
lactation. 

While the generative functions of the ovaries are held in abeyance 
by lactation, — or, if I may express it differently, while the ovaries are 
engaged in the reflex duties of sustaining lactation, — they do not re- 
turn to their former condition. According to my observation, involu- 
tion of the uterus, ovaries, and vagina is not complete in persons who 
nurse their children until the ordinary term of lactation has elapsed. 
Looked at in this way I think involution will present different feat- 
ures than when viewed from a more circumscribed standpoint. We 
will attach more importance to the influence of the nervous system, 
exerted through the ovaries. 

The term and process of involution extend to the changes observed 
in all the genital organs, the lacteal glands, the ovaries, uterus, vagina, 
Fallopian tubes, uterine ligaments, and perineum. How much more 
susceptible to the effects of morbid causes, therefore, must be all the 
contents of the pelvis in the hyperaemic, hypersesthetic, and hyper- 
trophic conditions during the time involution is going on, and how 
readily the affections of one pelvic organ will influence the condition 
of all the others. 

The genital organs constitute a separate and, in some respects, inde- 
pendent physiological system, governed by special nervous centres, all 



CAUSES — FREQUENCY OF ITS OCCURRENCE. 565 

bound together and dominated by the ovaries, under all the physio- 
logical changes accompanying pregnancy, labor, and involution. 

Causes. 

Any morbid causes that prolong the processes of involution may 
arrest the process entirety. The character of the labor may have this 
effect. If it has been tedious enough to produce great nervous ex- 
haustion, the uterine fibres will be powerless to conduct the changes 
necessary to a speedy and perfect involution. 

If the cervix is lacerated or badly contused, the consequent inflam- 
matory reaction interrupts involution for a greater or less length of 
time, or perhaps for all time. 

Inflammation of the body of the uterus resulting from severe labor 
or exposure may do the same thing. General and special causes not 
dependent upon labor often act so as to bar the completion of in- 
volution. Some of these causes are general debility, an impoverished 
condition of the blood, lack of nervous energy, a want of the powers 
of endurance, cold acting through the nervous system upon the circu- 
lation of the uterus post-partum or during menstrual congestion, the 
excitement of anger, fevers, or the depression of fear, etc. 

Special causes operate through the genital nervous centres upon 
the uterus directly, as venereal excitement from unnatural lascivious 
practices, coition during or just before menstruation and within 
the month after labor, libidinous literature, and exciting exhibi- 
tions. 

Diseases in the surrounding organs, by keeping up nervous and 
vascular excitement, ulceration, fissure, and hemorrhoids of the 
rectum, specific vaginal inflammation, laceration of the perineum, 
urethral and vesical inflammation, displacements of the uterus, etc., 
all tend to produce this effect. 

Frequency of its Occurrence. 

Without exaggerating the importance of subinvolution, I believe it 
would be correct to say, that more of the chronic congestions of the 
uterus originate in puerperal and menstrual subinvolution as here 
explained than in any other one condition. 

By taking the puerperal and menstrual involution as a fundamental 
and almost constantly present condition of the pelvic organs for a 
basis, I think we can better explain the mode of operation of exciting 
causes in producing chronic diseases than by any other hypothetical 
method. Certain it is, that there is no other organ in the body so 
prone to lesions of circulation and their consequences as the uterus, 
and that the reason why this is the case must reside in the anatomy 
and functions of the organ. 



566 SUBINVOLUTION OF THE UTEEUS. 

It is an organ, the very nature of whose condition is one of unceas- 
ing fluctuation of vascularity and nervous susceptibility. 

Symptoms and Diagnosis. 

The general symptoms of subinvolution are in no respects distinc- 
tive. All the reflex symptoms spoken of as uterine symptoms, or 
symptoms of uterine disease, may exist in patients the subjects of this 
condition; neither do the local symptoms guide us with certainty to 
a correct diagnosis. In the earlier months of subinvolution, in fact 
for an indefinite term, metrorrhagia is a frequent symptom, and in 
some instances continues as long as the disease lasts. It represents 
what may be termed the vascular stage of subinvolution. In a great 
many cases of subinvolution after a certain time, which also is very 
indefinite, the bloody discharge from the uterus becomes less copious, 
and occasionally entirely ceases. The diminution of the flow indi- 
cates the supervention of the fibrino-plastic stage, or a condition in 
which the vascularity of the uterus is diminished while the solid 
tissue is increased. Leucorrhcea is generally present or absent under 
the same conditions that govern the flow of blood. 

Diagnosis. 

The diagnosis must be made up from the history and physical 
examinations. If the sufferings of the patient date from an abortion, 
or labor at full term, and in addition to the general and local symp- 
toms of uterine disease there is or has been for months too copious or 
too frequent menstrual discharges, or hemorrhages intervening be- 
tween the regular periods, the presumption is that there is subinvolu- 
tion, or at least that the symptoms were at first those of that condi- 
tion. One of the most constant appreciable conditions of subinvolution 
is the large size of the uterus. This may be ascertained by bimanual 
examination and the introduction of the sound. 

When the uterus is lifted up by the fingers in the vagina, the fundus 
will be more easily felt by the hand above, and the sound will pass 
farther beyond the normal depth into the cavity than when the organ 
is of a normal size. 

The shape of the uterus is generally still that of the post-partum 
organ. It is proportionately thicker through its antero-posterior 
diameter. The enlargement, therefore, is different from enlargements 
from other conditions. 

The shape is often modified by retroflexions and lacerations of the 
cervix. When retroflexed without laceration, the fundus and body 
are much larger proportionately as compared with the cervix. When 
the cervix is badly lacerated, it is enlarged. The appearances in this 
respect are sometimes deceptive when the labia are widely separated. 



PROGNOSIS — TREATMENT. 567 

When examined through the speculum the color is deeper than 
natural, the mouth patulous, the cervix large and often ulcerated. 
Generally, also, there is copious albuminoid mucus hanging from the 
os uteri, sometimes of an amber color, from the admixture of pus- 
corpuscles. When the cervix is lacerated, the mucous membrane of 
the cervical cavity is exposed, and presents a papillary or fungoid 
appearance. 

These are the appearances in the vascular stage of subinvolution. 
After this has passed, and the fibrino-plastic change has taken place, 
the cervix and body will feel hard to the touch ; sometimes the indu- 
ration in such cases is very marked indeed. While the induration is 
generally uniform with respect to the cervical circle, and extends en- 
tirely around, at other times it is confined to one of the lips. Then 
the color is often not increased, and the surface is smooth and covered 
with cicatricial tissue instead of granulations or fungoid bodies. 

Prognosis. 

During the vascular stage of subinvolution, and while the hyper- 
trophied fibres of the uterus retain their muscular character, we may 
hope to succeed in restoring the normal condition of the organ. We 
must remember, however, that metrorrhagia, indicating great vascu- 
larity of the uterus, is no evidence that the fibres are not greatly 
changed or replaced by non-contractile tissue, and consequently the 
prognosis should be guarded. The longer the time the case has 
lasted, the greater the probabilities are that the fibres are replaced by 
connective tissue. 

After this vascular and hypertrophic condition of the muscular 
fibres have passed away, and there has been extensive fibrino-plastic 
deposit in the walls of the uterus, the probabilities of a cure are very 
remote. The uterus is then hard, inelastic, its tissues permeated by 
few vessels, and the nerves diminished, if not entirely absent. 

Treatment. 

The preventive treatment should begin during pregnancy. Every 
means necessary to place the patient in good health, both generally 
and locally, must be resorted to, — exercise in the open air on foot, 
if at all practicable, and domestic employment or exercise of like 
character. 

The habits of the patient should be regulated with a view to the 
development of the muscles of the entire body, while her diet should 
be abundant in quantity and of the most nutritious quality. 

It is not my purpose at this time to do more than to call the atten- 
tion of the obstetrician to the subject of preparing patients for the 
great task of passing safely through labor. During labor everything 



568 SUBINVOLUTION OF THE UTERUS. 

should be conducted with the view of preserving the integrity of all 
the soft parts, because, as before intimated, damage to any of the 
parts concerned in labor is pretty sure to be followed by subinvolu- 
tion. 

The more physiological a labor is, and the more skilfully conducted, 
the less the tendency to subinvolution. 

After labor complete contraction should be brought about, and 
maintained, not by mechanical irritation, but, if need be, by the use 
of ergot and vaginal injections of hot water. These latter will stimu- 
late the pelvic nerves and prompt the uterus to contraction, and by 
their cleansing effects promote the repair of every damage that the 
soft parts may have sustained. Above all things, a sufficient amount 
of absolute rest must be enjoined to insure recovery of the viscera, 

The most assiduous attention should be especially given to control 
all inflammations that follow labor. 

From the immense number of gynecological cases traceable to labor, 
it is to be feared that some of the modern innovations in the practice 
of midwifery are not improvements. 

More attention and care in conducting patients through cases of 
abortion and premature labor should be practiced than is usually 
done. 

Abortion is looked upon by the patients themselves as a small mat- 
ter, and it is very difficult to induce them to give the necessarj^ time 
and care to themselves. Physicians know that it is a more disastrous 
process than labor at full term, and they will do service, therefore, by 
enforcing proper measures, whenever it is practicable, to insure good 
recovery from it. 

After the patient has passed from the hands of the accoucheur to 
those of the gynecologist the treatment of subinvolution will be gov- 
erned by the conditions in each case. Until the muscular fibres have 
lost their power of contraction, ergot, strychnia, quinine, and iron, 
with good, nutritious diet and exercise in the open air, will be the gen- 
eral remedies most efficacious. 

Ergot, given in moderate doses, perseveringly administered, is a very 
powerful means of supplementing the natural contractions. It is not 
applicable to cases, however, where there is inflammatory excitement 
in the uterine substances, and should be withheld until, by alteratives, 
counter-irritants, and rest, that condition is removed. When this 
inflammatory condition is not present the ergot and tonics, judiciously 
administered, will co-operate well in the accomplishment of the gen- 
eral result. However, gynecologists do not often see these cases until 
the contractility of the fibres has been very much impaired, if not 
entirely lost. In most cases, even thus late, the ergot and tonics will 
have some good effect. 

In chronic cases the local treatment is of prime importance ; and 



TREATMENT. 569 

the first thing to be thought of is the removal of any cause of increased 
vascularity that may be found associated with it. If there is lacera- 
tion of the cervix or perineum it should receive attention. If there is 
misplacement it must be corrected, so that the outgoing circulation 
may be as free as possible. When these conditions are corrected we 
may begin a system of local treatment that will remove the congestion, 
and cause the absorption of the fibrino-plastic deposits. The use of 
glycerin tampons and hot-water injections will be found applicable 
and beneficial in most cases. The glycerin cotton should be applied 
about every second or third day, and allowed to remain in the vagina 
from twenty-four to forty-eight hours. It should support the uterus 
so as to relieve the tender or irritated pelvic tissues of all strain. 

During this time the capillary bloodvessels will be depleted by the 
loss of a part of the serous portion of the blood they contain, and ex- 
osmosis from the intervascular spaces will also be excited in such a 
manner as to empty them of their contents. This leaves the part with 
which the glycerin comes in contact white, shrivelled, and lessened in 
bulk, i. e., depleted. This is not all the good effect produced by the 
glycerin applied to the cervix of the uterus, for the frequent removal 
of the serum from the intervascular spaces, which, of course, is replaced 
by a fresh supply from the vessels, is a very efficient means of dissolv- 
ing out the fibrino-plastic material. It is, in fact, a kind of washing 
out of the tissue with serum derived from the minute bloodvessels ; it 
acts, therefore, both as a depletent and a solvent. 

Large hot-water injections constitute another valuable means of 
overcoming hyperemia, and causing absorption of solid deposits. 

But there is another class of local remedies that is more serviceable 
than these, and that is local stimulants applied directly to the mucous 
membrane, such as iodine, carbolic acid, tincture of iron, acid nitrate 
of mercury, and many others that I might mention. In the teachings 
of twenty-five years ago the application of these remedies to the mu- 
cous membrane was supposed to exert only a very limited influence 
at the point to which they were applied, and we thought in applying 
nitrate of silver to an abraded or ulcerated surface the only effect it 
had was to heal up the abraded patch. Now we know that this is a 
very small part of the effect of these local applications. The vasomotor 
nerve supply of the whole uterus is so intimately connected that it may 
be considered a unit, and no part of it can be stimulated without affect- 
ing the whole. Applications made to the cervix of sufficient strength 
to stimulate its circulation to greater activity affect every fibre and 
capillary in the organ in a similar manner. When, therefore, there is 
chronic engorgement of the uterus, the very best way to get rid of it is 
to stimulate the circulation by local applications to the cervix. This 
same principle may be turned to great advantage by stimulating its 



570 HYPEEIN VOLUTION. 

internal mucous membrane, and one of the best ways to do this is to 
scrape the cavity of the uterus with a dull wire curette. 

This instrument may be introduced in most instances without diffi- 
culty, and passed slowly but firmly over the whole surface. In some 
instances, where the mucous membrane is soft, small pieces may be 
brought out by the instrument, but generally this is not the case. 

When pieces of the mucous membrane are thus removed it would 
be too mechanical an explanation to say that the patient is cured be- 
cause the uterus has been partly or wholly divested of its diseased 
membrane. It is the excito-motor influence exerted on the nerves, 
and the consequent effect upon the whole circulation of the organ, 
that is the result of its use. 

It is not merely to the hemorrhagic condition of subinvolution, but 
to the hypertrophic condition also, that the curette is applicable. 

Dilatation with compressed sponge has often accomplished good in 
the same kind of cases as those to which the curette is adapted, but it 
is a much more hazardous measure, and should only be resorted to 
when the other means fail. 

Hyperinvolution 

Is the state of the organ in which the involution has proceeded to 
such a degree as to condense the tissues beyond their ordinary density. 
The condensation thus accomplished renders it less vascular and erec- 
tile, and the fibrous structure is paler and harder than natural. As 
the result of this condensation and diminution in the quantity of the 
circulation, the uterus as a whole is smaller and lighter than common. 
The degree to which hyperinvolution may be carried varies greatly ; 
sometimes it is so slight as to require great care to distinguish it, at 
another the uterus is reduced to half its ordinary weight and di- 
mensions. 

Causes. 

Inflammation seems here to be more concerned in the production 
of hyperinvolution than any other morbid process. From examina- 
tions during the progressive steps of morbid states of involution, I 
am inclined to think that in cases where inflammation of the mucous 
structures exists exclusively, or where inflammation of the mucous 
membrane preponderates, the involution is arrested, and hence we 
have subinvolution ; but when the inflammation is mostly confined 
to the submucous tissue it proceeds to hyperinvolution. 

Symptoms. 

The condensation of the tissue and reduction of the vascularity of 
the organ always diminish the menstrual flow ; and hence we have de- 
creased menstruation in a moderate degree, and obstinate amenorrhcea 



DIAGNOSIS. 571 

in the more extreme condition. The symptoms attendant upon hyper- 
involution are very similar to those enumerated in the description of 
chronic inflammation. They are sometimes very distressing, rendering 
the patient thoroughly miserable for many years. The worst cases of 
this form of diseased involution I have met with have been traced to 
inflammation resulting from abortions ; but it likewise takes place as 
the effect of inflammation after ordinary or full term parturition. 

Diagnosis. 

The diagnosis is easy with the aid of the uterine sound. This in- 
strument will not enter the uterus as far as it does into a healthy organ. 
The uterus is lighter and more easily moved, also, by the finger intro- 
duced into the vagina. 

One of the almost invariable effects of hyperinvolution is sterility. 
I have met with a number of cases of sterility occurring soon after 
marriage, on account of abortion, in the first three or four months, 
being followed by inflammation and hyperinvolution, the patient ever 
afterwards remaining sterile. 

The successful treatment of these cases requires a great deal of 
patience and well-adapted measures. If the change in the condition 
of the uterus is slight we may sometimes succeed by introducing a 
bougie of slippery-elm bark, large enough to distend the cavity of the 
cervix as much as practicable, three or four days before the expected 
menstrual discharge. This seldom fails to increase the discharge, and 
if used perseveringly for several months will sometimes cure the case. 
The bougie should be cut out of the bark so as to be about an inch 
and three-quarters in length, for cases of moderate contraction, and 
secured by a thread before introducing it. It should be allowed to 
remain until the discharge begins, and then removed. If, however, 
it is of long standing, and the diminution in size very considerable, 
we will be under the necessity of using the stem-pessary recommended 
by Professor Simpson. It may be made of zinc and copper, in order 
to add the influence of galvanism. 



CHAPTER XXXV. 

CANCER OF THE UTERUS. 

"Those growths maybe termed cancerous which destroy the natural 
structure of all the tissues, which are constitutional from their very 
commencement, or become so in the natural process of their de- 
velopment, and which, when once they have infected the constitu- 
tion, if extirpated, invariably return, and conduct the person who is 
affected by them to inevitable destruction." (Miller, as quoted by 
West.) 

This general definition of cancer will include all its varieties, which 
are usually divided into four : 1st, medullary ; 2dly, epithelial ; 3dly, 
colloid ; 4thly, scirrhus. I have mentioned these varieties in the 
order of frequency in which they usually occur in the uterine tissues. 
I have not seen either a case of colloid or scirrhus in the uterus. 
There can be little doubt, however, that both are met with. The 
medullary variety is by far the most common form with which this 
organ is affected, the epithelial being also quite common. Cancer of 
the uterus is of very frequent occurrence, and the deaths from it, com- 
pared to death from the same disease occurring elsewhere in women, 
predominate over all other localities. It attacks the cervical portion 
of the uterus more frequently than all other parts of the organ, yet it 
begins in every other portion, — in the fundus, body, or cavities of the 
body or cervix. In some rare instances it runs its course to fatal re- 
sults without involving all these parts. When it begins in the cervix, 
it usually, either gradually or suddenly, passes upward to the fundus ; 
or if beginning in the fundus or body, it creeps downward to the os 
tincse. I have seen two instances where the lower portion of the cer- 
vix was but slightly, if at all changed, while all the other parts of the 
organ were infiltrated by cancerous deposit. The material of cancer, 
particularly the medullary, is deposited in the tissues, supplanting 
them more or less perfectly. 

The tissue most commonly attacked by all the varieties except the 
epithelial is the connective tissue. The parts attacked are thickened 
and indurated, the thickening and induration being very irregular in 
shape and size. If one of the lips of the os uteri is hardened from 
cancerous deposit, the elevated points are sharp and angular, and the 
hardened parts terminate abruptly, and in a manner unlike the in- 
duration from any other cause. The hardening from inflammatory 
fibrinous deposit is more globular than angular, and less abrupt in 
its termination in the sound parts. If the cancerous deposit is in the 



CANCER OF THE UTERUS. 573 

body or side, or any part of the wall, it is enlarged into an irregular 
shape, and there are pits and points in many places. 

The infiltration and induration increase for an uncertain length of 
time, until, perhaps, the cancerous deposit so far displaces and re- 
places the ordinary tissues that the nutrition of the parts is disturbed 
by the destruction of the bloodvessels, and sloughing takes place over 
a small or large space, but always over an irregular space, thus leav- 
ing a greater or less chasm. This is ulceration, — cancerous ulcera- 
tion. The absorbents do not remove the parts, and thus cause ulcera- 
tion, but there is sloughing and denudation by death of many minute 
parts, the absorbents having but little to do in the process. The 
sloughing causes the smell and putrilaginous character of the dis- 
charges. This process widens and deepens the chasm, sometimes 
quite rapidly, at others very slowly. In the case of the medullary 
variety, after induration and enlargement have advanced to a con- 
siderable extent in the uterus, the nutrition of the neighboring organs 
and tissues is disturbed, and the deposit is infiltrated into all the sur- 
rounding parts, — the bladder, the rectum, the areolar tissue by the 
side of the uterus, the peritoneum, in fact, into everything in the 
neighborhood. This general deposit is not limited by the coverings 
or divisions of the parts, but all become united, so that all the pelvic 
tissues become one agglomerated mass of cancer ; or, if it take one 
direction more than another, the bladder and uterus may be glued 
together, or the rectum may be bound thus to the uterus. This dis- 
position of the deposit very soon becomes sufficient to fix the uterus 
immovably in its place. 

After the ulcerative process has fairly begun, it advances more or 
less rapidly, until much of the surrounding parts is destroyed ; the 
bladder and uterus become one continuous cavity, and sooner or later 
the rectum also is laid open, and then the pelvic viscera are involved 
in one confused excavation, from which the putrilage of cancerous 
degeneration is poured out, commingled with urine, faeces, and blood. 

There is quite a constant proportion between the rapidity of the 
destructive progress of cancer and the age of the patient. It is slower 
in the aged, and destroys the young patient most readily. Of three 
cases under observation, in which cancerous deposit began in the body 
or fundus of the uterus instead of the neck, two w T ere in patients be- 
yond the climacteric period, one being sixty-four years of age and the 
other fifty-seven when the symptoms first attracted their attention. 
The other patient was forty-three. In this last patient, simultane- 
ously with the evidence of deposit in the body of the uterus, signs of 
it appeared in the bladder, vagina, and clitoris, the duodenum, and 
in the pyloric orifice of the stomach. I always look for a more rapid 
degeneration of the tissues invaded by cancer in comparatively young 
patients. 



574 CANCER OF THE UTERUS. 



Symptoms. 



Discharges, pain, and fetor are the symptoms that usually attract 
our attention in cases of cancer of the uterus. When a patient com- 
plains of any of these, however, the case is generally an advanced 
one. Pain, perhaps, is the symptom first experienced, and is caused 
earlier than any other. Unfortunately, pain is so common to women 
— they suffer so often in the regions of the uterus and hips — that this 
symptom is not heeded by them until some other symptom makes its 
appearance. The pain is not generally intense nor troublesome until 
after the disease is recognized. Nor is it peculiar. It is described 
as lancinating, darting, twinging, — and very correctly, too, — but there 
is often no pain of this kind during the whole course of uterine 
cancer. 

The discharges in cancer are of three kinds, and the mixture of 
them in different proportions. They are: 1st, blood; 2d, limpid 
serum ; 3d, sloughs, generally minute. The first two are not offen- 
sive to the smell when pure or mixed together, as they often are, and 
they only become so by being mingled with the last, by dissolving or 
holding in suspension or being merely mixed with greater or less 
pieces of dead tissue. In the earlier stages of cancer blood or serum 
may be, and generally is, effused, while the latter is reserved to the 
open or ulcerated stage. In this open or ulcerated stage all three 
kinds of discharges are almost always mixed together. In women 
who are still menstruating, the discharge first experienced is of blood. 
There is, at first, an increase in the amount of menstrual discharge ; a 
little later, and blood is lost between the times of menstruation. The 
blood thus lost is derived from the same source as the menstrual 
blood,— the vessels of the mucous membrane of the corpus uteri. 
Later, when hemorrhage is so constant and attended with fetor, it is 
effused from eroded vessels upon the ulcerated surface. 

The blood in the former case is produced as the result of constant 
turgescence ; in the latter, on account of the disintegration of tissue. 
Limpid, unoffensive serum is almost always observed in the cases of 
old women, after the menstrual period of life has passed, and gener- 
ally coming from the os uteri, which may be for a long time un- 
changed, indicating that it comes from some distance up in the organ. 
In fact, if the same serum was effused from the surface of the vaginal 
portion of the cervix it would most likely be mixed with blood, be- 
cause the parts producing it would not be sufficiently protected to 
insure the integrity of such frail tissue. In two remarkable instances 
the copious discharge of this limpid serum was, for many months, the 
only sign of disease presented by the patients. One of my patients, 
sixty-one years old, had been under the necessity of wearing napkins 
for six or more months before calling my attention to her condition. 



SYMPTOMS. 575 

The discharge was so copious when I saw her for the first time that I 
collected about two drachms from the speculum in ten minutes. 
When examined it was found to resemble distilled water in appear- 
ance, it was so clear and colorless. There was no smell nor other 
offensive quality to it. When examined by the microscope no solid 
substances were found, except a very few natural epithelial scales. 
In a very gradual manner this transparent liquid became colored with 
blood. It was sometimes clear and sometimes bloody for several 
months before becoming fetid, and only for a few weeks before the 
patient died was it constantly bloody and fetid. The cervix uteri in 
this case was not attacked at all, and the mouth and lips of the neck 
were natural. The body of the uterus, as high as the fundus, was 
enlarged more than double its natural size, indurated, and nodulated ; 
and, when examined after death, the walls presented the peculiar 
friable hardness of medullary cancer, but there was no excrescence in 
the cavity, as I bad expected to find. 

Whether the discharge is blood or serum at first, or a mixture of 
both, it is generally odorless ; but after a time it becomes fetid, and 
remains so persistently. The fetor appears, from the testimony of 
most observers, to be peculiar ; but I have not been able to distinguish 
it from the smell of putrilage of other productions. When all these 
symptoms unite they form a case almost unmistakable. Lancinating 
pain, sero-sanguineous discharge, and peculiar fetor, continuing per- 
sistently, are almost distinctive of cancer. 

I cannot lay much stress on either one of these symptoms; but of 
the three the most importance should be attached to the fetor. Per- 
sisting for weeks it should cause us to suspect a cancer. Contempo- 
raneous with the complete establishment of these symptoms we have 
constitutional suffering. It is not often, I think, that general suffer- 
ing precedes the local symptoms of cancer, and it has always seemed 
to me to follow as the effect of local disease. It has not been my lot 
to meet with the broken-down constitution sometimes said to be gen- 
erated by the cancerous diathesis. Cancerous ansemia, causing the 
straw-colored translucency of the skin, considered characteristic of the 
malignant cachexia, is not distinguishable from the hemorrhagic 
anaemia occurring sometimes in persons of the same age, produced by 
the drain upon the blood. 

In the fully-developed condition of carcinoma the constitution 
suffers, and the collection of symptoms are such as arise from the 
embarrassment and failure of the functions in a long struggle with 
pain, loss of blood, anxiety, and inaction. Debility, with indigestion, 
palpitation, restlessness, neuralgia, constipation at first, colliquative 
diarrhoea and aphthse toward the end, nightsweats, wandering of 
mind, unsteadiness of purpose, succeeded by delirium and apathy ; in 
fact, all the train of symptoms which precede dissolution when it ap- 



576 CANCER OF THE UTERUS. 

proaches through protracted struggles, in which pain and exhausting 
discharges are the destroying agencies. 

Causes. 

But little can be said as to the causes of cancer of the uterus. The 
general opinion that it is hereditary in most cases is, doubtless, true; 
and yet a great many instances occur that cannot be traced to such a 
cause. This is no reason why they may not be hereditary, because 
sometimes the circumstances which permit the hereditary taint to 
show itself do not exist for a number of generations. And again, the 
taint may be so dilute as to require very favorable circumstances or 
co-operating causes to bring it out. If a mother dies of cancer at the 
age of forty-five, and impart the same morbid tendency to her daugh- 
ters, the laws of cell-development would bring it about at the same age 
in the child. If, therefore, the daughter dies a year too soon of some 
other disease, the taint is inoperative, though present. Two or three gen- 
erations of cancer-bearing persons cut off by other diseases lose the his- 
tory of its inheritance. Or if a mother be the subject of cancer at the 
end of a life of active, nay, excessive, child-bearing, while her daugh- 
ter leads a life of celibacy, or has but a single child, the physiological 
life of the two is so different that we would naturally expect some modi- 
fication of consecutive cell-development to result. So that, although 
the hereditary taint is the same in the two, their pathological ages may 
differ, and the daughter may not have cancer until a later period, and 
die before that time arrives. We should, I think, allow much for 
influences that may modify hereditary taints, and only regard them 
as hereditary tendencies, to be brought out in mother and daughter 
under similar circumstances, and which may be postponed or pro- 
duced earlier in the one or the other by certain conditions. 

Married women are affected more frequently than the single, and 
the fruitful than the barren. When we consider how many more 
married than single women there are in civilized communities, and 
how few married women are sterile, we ought not to attach much 
importance to these facts. A much more significant fact is that a 
very large majority occur during the menstrual years of a woman's 
life. It is true that there may be nothing more than a mere coinci- 
dence in this fact, and that, after all, the hereditary mutations in the 
system during these years may bring about cancerous deposit, inde- 
pendently of any connection with the menstrual function. But it 
certainly is a coincidence, if not an etiological coincidence. As to 
the connection of cancer with chronic inflammation and ulceration of 
the uterus, much has been and may be said. I cannot lay my hand 
on statistics upon this subject, but I have never observed the coinci- 
dence of inflammation and cancer, or that cancer was a consequence 
of inflammation. If, however, they are occasionally connected, there 



DIAGNOSIS. 577 

are but few at the present day who believe cancer to be the result 
of long-continued inflammation. 

Diagnosis. 

It would seem that the diagnosis of a disease so marked as cancer 
would be an easy matter, and so it is when all or even most of the 
peculiarities of the disease have been fully developed ; but in the very 
beginning there may be much obscurity. A patient complaining of 
nothing more than a perfectly clear, inodorous, watery discharge, 
seemingly in the enjoyment of good health, would hardly be regarded 
as a victim to one of the most surely fatal and loathsome diseases 
incident to the human race ; and yet it is almost invariably so when 
the patient is advanced beyond the epoch allotted to menstruation. 
The cancerous disease, as it usually occurs, advances beyond the 
period of doubtful symptoms in a very short time, and in the majority 
of cases our attendance is not requested until a scrutinizing examina- 
tion will enable us to decide very positively on the nature of the case. 
Our attention will be attracted by the unusual amount and character 
of discharge, pain, and smell. 

The following characteristics of beginning carcinoma are given by 
Stratz : * 

1. The diseased portion has a definite and well-defined contour, and nowhere 
merges gradually into the healthy tissue. 

2. There is always a perceptible difference in the diseased portion as a whole, and 
the healthy. 

3. The carcinomatous tissue always has a yellowish tinge of color. 

4. The malignant spots show small, hard, yellowish-white elevations, at least in 
places. 

It is not necessary to insist on the importance of an early diagnosis, 
since it is only in the early stages that we may hope to effect a per- 
manent cure. 

Summary of appearance in cases from Becquerel : 

" Cancerous Deposit. 

Cervix hard, unequal ; nodulated, os not always open, sometimes wrinkled or fur- 
rowed. 

Cancer of the neck often implicates the vagina. 

Hereditary influence is often traceable. 

Touch is painless. 

Discharge sometimes absent, in certain cases very abundant, and consisting, for the 
most part, of albuminous serum. 

Menstruation increased, being neither more nor less painful, and passing often into 
the state of real hemorrhage. 

* Zeitsch. f. Geb. und Gyn., 1886, vol. xiii., No. 1. 
37 



578 CANCER OF THE UTERUS. 

Absence of special anaemia when the vagina and body of the uterus are involved. 
Cancerous cachexia. 

Progress continuous and without cessation. 

The pain in cancer is very sharp, intense, and lancinating, and not influenced by 
locomotion or movements of any kind." 

" Ulcerated State. 

Developed at the critical period of life generally. 

Preceded and accompanied by hemorrhages. 

Severe, sharp, lancinating pain. 

Development essentially in sharp irregularities and nodosities. 

Adhesions to other organs soon as ulceration is formed ; immobility of the uterus. 

The surface only slightly soft ; subjacent tissue scirrhous. 

Ulceration deep, unequal, essentially irregular, with thick, elevated, and hard 
edges. 

Always granulations. 

Discharges extremely abundant, consisting of purulent and often sanguineous serum ; 
nauseous and often fetid odor. 

Great hemorrhage from time to time, not necessarily at menstrual period." 

" Cancerous Ulceration. 

Developed upon an hypertrophied and scirrhous surface. 

Ulceration, deep, vast, unequal, grayish surface with thick edges, and easily 
bleeding. 

Ulcerated surface hard, presenting numerous lobes and tubercles, with nodosities 
and great hardness. 

Often great loss of substance. 

Cervix and corpus uteri immovable on account of adhesions. 

Discharges sanious, fetid, sanguinolent, and of an insupportable and characteristic 
odor. 

Cancerous cachexia always present." 



Prognosis. 

The prognosis of cancer is a gloomy one. Indeed, there is no dis- 
ease which so uniformly terminates fatally as cancer of the uterus. 
Notwithstanding this fact forces itself upon our observation, there will 
sometimes, in the course of a large experience, occur a recovery from 
it spontaneously and unexpectedly. I need not enter into the dis- 
cussion of the causes of this fatality. Whether the disease is essen- 
tially a blood-disease, or whether primarily local, there are but few 
instances in which it is not multilocular. It exists from the begin- 
ning, or very soon afterwards, in more than one place. Yet again, 
this is not invariably the case. We very seldom meet with an in- 
stance in which the area of deposit is small and confined to one 
locality. If this locality is accessible, the case possibly is curable. I 
say possibly, because the pathology is treacherous. This gloomy pic- 
ture is in part relieved by the greatly improved palliative means we 



TREATMENT. 579 

now possess. Very much may be done to allay the agonizing state 
of body and mind under its ravages. 

Treatment. 

Both medicinal and surgical means fail to give the profession 
much satisfaction in the treatment of cancer of the uterus. When 
the disease is clearly confined to the cervical portion of the organ, 
amputation of that portion holds out a very faint hope of cure. It is 
so common for the cells constituting the main bulk of the deposit to 
be scattered far beyond the apparent margin of the disease, that much 
more frequently than otherwise an abundant crop of them is left 
behind to continue the work of destruction. Very rare instances of 
cure are reported. 

While, then, it is our duty to give our patient even a remote chance 
for recovery, we cannot hold out much hope of radical cure by re- 
moving the cervix. 

The same is true in reference to the operation for extirpating the 
entire uterus. The immediate danger attending the removal of the 
cervix need scarcely enter into our calculation of the benefits that 
may arise from it. This cannot be said, however, of the operation for 
exsecting the whole uterus. The dangers in this operation are mani- 
fold, while the immunity from a return can be counted upon in only 
a small proportion of cases. Nevertheless, the recent improvement in 
the statistics of vaginal hysterectomy, together with the possibility of 
an earlier diagnosis than formerly, are giving surgeons great encour- 
agement. 

I do not think the operation can be sustained by success until the 
immediate dangers are very much diminished. (For these operations 
see Epithelioma.) 

Can we reasonably hope for a cure of cancer by medicine ? I think 
this question can be unqualifiedly answered in the negative. 

I full} T believe that the rapidity of growth may sometimes be re- 
tarded, and possibly stayed for a length of time. Many medicines 
have enjoyed the reputation of curing cancer, and have been used 
with implicit faith, but I may safely say that not one does at the 
present time. I need not stop to inquire how such reputation could 
have been acquired, except to say that until within a comparatively 
recent date other and curable diseases were mistaken for cancer. 
Quite lately we have been assured of the great powers of cundurango 
in this direction, and for a time there were very slight reasons to hope 
that it was a useful i£ not a curative means in the treatment of cancer. 
It has enjoyed a place in the category of cures for cancer for a shorter 
time than many others. 

Within a few months a beam of light has fallen upon the subject 



580 CANCER OF THE UTERUS. 

which has again awakened the hope that possibly we are on the eve 
of finding a medicine capable of influencing this destructive cell- 
growth. 

Professor John Clay* obstetric surgeon to the Queen's Hospital, 
Birmingham, has had some very fortunate experience with Chian 
turpentine in uterine cancer. The statement, coming from one whose 
professional character, so far as I know, cannot be impeached, and 
published in the staid old journal, the London Lancet, must command 
general attention. Considering our experience in the cure of cancer 
the results obtained by him seem marvellous, and for fear of marring 
the face of his report I abstain from making my own summary, but 
will quote his case in full, together with some of his remarks. 

" A woman came to the hospital as an out-patient, aged fifty-two. She was suffer- 
ing from scirrhous cancer of the cervix and body of the uterus. Hemorrhage was 
excessive, pain of the back and abdomen agonizing, and cancerous cachexia well 
marked. The patient evidently had not a long time to live. The uterus was so ex- 
tensively destroyed by the cancerous ulceration that its cavity readily admitted three 
fingers. In such a case it appeared to be justifiable to attempt to relieve the suffer- 
ings of the patient, even if the remedy should produce unfavorable symptoms, or 
should prove of no avail. I therefore prescribed Chian turpentine, six grains; flowers 
of sulphur, four grains; to be made into two pills, to be taken every four hours. No 
opiates were prescribed or lotion used. No change was to be made in her diet or 
occupation. On the fourth day after taking the medicine the patient reported herself 
greatly relieved from pain, and was in better spirits, but she complained of a large 
amount of discharge. It was feared that she referred to a discharge of a sanguineous 
nature. On examination, however, the vagina was found to be filled with a dirty- 
white secretion, so tenacious as to be capable of being pulled out rope-like, and this 
although she had syringed herself three hours previously. The os was quite con- 
tracted and would now scarcely admit the finger, and the surrounding swelling or can- 
cerous infiltration of the cervix was much reduced. On the twelfth day the thick 
tenacious secretion had almost disappeared, and was succeeded by a somewhat copious 
serous fluid. The os was not so firmly contracted, but would only admit the finger. 
The patient's general health was improved and the medicine well tolerated. Sixth 
week: I ordered her a quinine mixture in conjunction with the turpentine, but sick- 
ness supervened, which ceased on omitting the quinine. Twelfth week : My notes 
are, — the parts feel ragged and uneven, and do not bleed on roughly touching them. 
The speculum shows several cicatricial spots. The turpentine has been taken regu- 
larly during the day for twelve weeks every four hours, during which time she has 
been almost free from pain and has had no hemorrhage: no glandular enlargement; 
general health improved. Walks easily to the hospital, being about a mile distant. 
As the patient did not come again to the hospital her address was obtained, and it 
was ascertained that she had left her residence. Being a widow she could not afford 
to keep her home, and she went to reside with her married daughter in a northern 
town, but left no address. The case showed that the medicine was one of great power 
in cancer of the uterus, and it is to be regretted that an opportunity was not offered for 
fully carrying out the treatment. 

" Another patient, aged thirty-one, suffering from cancer of the os and cervix uteri, 

* London Lancet, June number, 1880. 



TREATMENT. 581 

was treated concurrently with the one just mentioned. These parts were enlarged 
from carcinoma to the size of a hen's egg. The os was dilated, and the cavity of the 
cervix was filled with epithelial growths, which bled freely on examination. Sacral 
pain was very severe, and hemorrhage had been continuous for the previous six weeks. 
The Chian turpentine and sulphur were given as in the previous case. The patient 
again attended at the hospital on the seventh day after taking the medicine. She was 
in excellent spirits, and expressed her gratitude for the relief afforded her. The medi- 
cine entirely relieved her pain. She had increased white discharge. On examina- 
tion the os and cervix were found to be nearly of the normal size. The os was patu- 
lous, and its surface was studded with flabby shot-like eminences, which did not bleed 
on roughly rubbing them. I said to her : ' You are better ; you must continue the 
medicine.' She answered : ' I should think I must, for I could not do without the 
pills; they have eased me so very much.' She continued to improve, and on the 
fourth week she expressed herself as quite well. I impressed upon her the necessity 
of continuing the medicine, and told her to see me occasionally. She did not come to 
the hospital again for four months, when she brought another patient to consult me, 
believing that she was suffering from cancer. I reproved her for leaving off attend- 
ance at the hospital. She answered that she thought it unnecessary, as she had con- 
tinued quite well. On this visit she submitted to an examination. The os was rough 
and irregular, but was of nearly the normal size; no signs of cancerous infiltration; 
the periods were regular, and not profuse, and were unattended with pain ; there was 
slight leucorrhoea. This case was a most remarkable one. The turpentine acted upon 
the growth with great vigor, literally melting it away in the brief period of four or 
five weeks. 

"The third case was one of epithelial cancer of the os, cervix, and the body of the 
uterus, in a woman, aged fifty-two years. The vagina was not involved. The mass 
was larger than a cricket-ball, almost filling the vagina. The border of the os was 
three-quarters of an inch in thickness, forming a ring of two and a half inches in 
diameter, through which protruded an epithelial growth, principally proceeding from 
the anterior wall of the uterus, and projecting about two and a half inches into the 
vagina. The case was sent to the hospital for my opinion by my son, Mr. Langsford 
Clay, who had attended the patient but a short time. The journey to the hospital 
fatigued her very much, and she declared that she could not come again, and that she 
did not wish to remain as an in-patient, believing that she could not live many days. 
She had repeated hemorrhages, had much pain, and had the cancerous cachexia well 
pronounced. My son volunteered to attend her at home, and I agreed to see her 
occasionally with him. I thought it advisable, as an experiment, to vary the treat- 
ment somewhat, and ordered to be added to the pills one-sixth of a grain of the ammo- 
niated copper, as from the large mass to be acted upon I thought that an astringent 
should be superadded to the turpentine. The dirty- white, tenacious discharge, appeared 
and continued for the first five weeks, but there was no hemorrhage after the first 
examination. The swollen os uteri and the cervix beyond were the first to show signs 
of diminution ; this was noted on the fourteenth day. The tumor, however, was rough 
and shrunken, and did not project so much. Sixth week: The surface of the tumor 
was at the level of the os uteri, and seemed to consist of a mass of bloodvessels, which 
bled moderately after examination. This condition occasioned me some surprise, as 
three weeks previously the patient was ordered a lotion made with perchloride of iron, 
with a view to arrest hemorrhage, since from her anaemic condition it was feared that 
the loss of a moderate amount of blood would be followed by serious consequences. 
I asked her what kind of a syringe she used with the lotion. She replied, ' I thought 
the lotion was merely to bathe the external parts.' This, as it happened, was very 
satisfactory information, as it showed that the lotion had no share in the reduction of 



582 CANCER OF THE UTERUS. 

the mass, which now was scarcely half the original size. She was supplied with a 
syringe for the purpose of applying the lotion, and after using it three days the mass 
of vessels had considerably shrunken, and no longer bled on manipulation ; but the 
surface of the growth had the touch and appearance of a gangrenous mass, but there 
was scarcely any fetor. The patient now complained of gastrodynia, with colicky 
pains in the bowels, but she had no diarrhoea or vomiting. I believed this to be due 
to the copper, and it was consequently discontinued. It also appeared to me that the 
turpentine might not be efficiently digested in the solid form, and that it would be 
better if the remedy were administered in a state of minute subdivision, as in the form 
of an emulsion. An ethereal solution of Chian turpentine was prepared by dissolving 
one ounce of the turpentine in two ounces of pure sulphuric ether (anaesthetic). The 
ether dissolved the turpentine instantly. This solution was given to our skilful dis- 
penser, Mr. Whinfield, with a request that he would prepare a pleasant mixture or 
emulsion from it ; and, after a few trials, he prepared one which is not unpleasant to 
take, according to the following formula : Solution of Chian turpentine, half an ounce ; 
solution of tragacanth, four ounces ; syrup, one ounce ; flowers of sulphur, forty grains ; 
water to sixteen ounces ; one ounce three times daily. This form of mixture was 
given to the patient, and was much liked. She has now taken the turpentine for 
thirteen weeks uninterruptedly. The os uteri is a little more than one inch in diame- 
ter, and feels like a ring of cartilage about a quarter of an inch in thickness. The 
tumor has nearly disappeared, and the finger can be introduced posteriorly into the 
uterus for more than an inch. The general health has much improved, and she is 
quite free from pain and looks cheerful, and is becoming stouter. No sedative what- 
ever has been given during the treatment. Fourteenth week: She complained of 
severe 'cramp-like pains' in the back and lower part of the abdomen, which she 
attributed to the mixture, and in consequence it was discontinued for a few days, and 
an opiate given, by which she was greatly relieved. The turpentine was again 
resumed. Nineteenth week : She is now fairly convalescent. The growth has almost 
disappeared, and the parts beyond the os uteri are somewhat hypertrophied, yet are 
almost normal to the touch. 

"The fourth case was that of a patient aged thirty-two years, who came to the hos- 
pital after having been discharged as incurable from the Women's Hospital. She was 
greatly depressed, and was most desirous to be cured, for the sake of her family of 
young children. She has had repeated fioodings, and suffered greatly from pain dur- 
ing the past five months. Constipation very troublesome, which probably arose from 
the opiates she had been in the habit of taking. On examination, she was found to be 
suffering from epithelial cancer of the os and cervix uteri, but not involving the vagina. 
There was a cancerous mass of the posterior parts of the os and cervix, of the size of 
a goose-egg. This growth pushed the os uteri towards the pubis, almost preventing 
that part from being felt. The turpentine mixture was given her three times daily, 
and from this period a very rapid diminution of the growth took place, so that by the 
sixteenth day it had almost entirely disappeared. The os uteri was now in situ, admit- 
ting the finger readily, and there was the same condition of the vessels as that observed 
in the preceding case. The lotion with the perchloride of iron was used daily for a 
few days with excellent effect. In the ninth week the patient suffered from spasmodic 
pains in the back and abdomen, and as this was attributed to the medicine, it was dis- 
continued, and iodide of calcium, in five-grain doses, three times daily, was administered. 
This was taken for about a fortnight, but, not feeling so well, the patient was admitted 
into the hospital. The condition of the internal organs was now much the same as 
before the iodide of calcium was given, but there was some thickening about the cervix, 
which was fixed to the vagina. The rectum was excessively loaded, and required 
several days to effectually relieve it The Chian turpentine was administered simply ; 



TREATMENT. 583 

but a lotion was prescribed, containing six grains of white arsenic to one pint of water, 
to be used daily. Under this treatment the woman very rapidly improved, the pains 
entirely ceased, and the parts became much reduced in size, and more movable. The 
patient was now anxious to leave the hospital for her home, as she felt quite well ; but 
it was deemed advisable to send her to the Sanatorium instead. She is very active, 
cheerful, and happy, and may be pronounced convalescent. 

"Other cases are under treatment, both in the hospital and privately, all showing 
similar effects. The remedy is now being tried in cancer of other organs, and ap- 
parently with good results. One of the most interesting, perhaps, is a case of scirrhus 
of the breast, which has been under observation for some weeks. Among the other 
cases are cancer of the vulva, stomach and abdomen, in which very remarkable benefit 
has been already produced. 

" From the results obtained by the use of Chian turpentine, it may be confidently 
said that the remedy does exert a powerful action on cancer of the female generative 
organs in particular, and it will be of advantage to point out some of the conclusions 
at which I have arrived respecting the efficacy of the drug, and the manner in which 
it should be employed. The oil of turpentine, if it produces any effect on cancer, is 
inadmissible on account of the speedy production of its specific effects even when 
administered in small doses. The same remark applies with less force to the Venice 
and Strasbourg turpentines ; in my hands they have not produced the same beneficial 
effects on cancerous growths as the Chian turpentine has done. The maximum dose 
of the last-named drug which can be safely and continuously given is twenty-five 
grains daily. It is advisable to discontinue the remedy for a few days after ten or 
twelve weeks' constant administration, and then to resume it as before. The combina- 
tion with sulphur was given at first, and has been continued. It is doubtful whether 
much benefit is derived from the combination, but the effects have been so uniformly 
good with it, that it was thought advisable to continue its use. There is every reason 
to believe, from the trials made with other substances in combination with the turpen- 
tine, such as carbonate of lime, iodide of calcium, ammoniated copper, quinine, ber- 
berine, hydrastin, etc., that the turpentine is best administered simply, as the most 
marked and rapid effects have always been manifested when it has been given alone. 

" The turpentine appears to act upon the periphery of the growth with great vigor, 
causing the speedy disappearance of what is usually termed the cancerous infiltration, 
and thereby arresting the further development of the tumor. It produces equally 
efficient results on the whole mass, seemingly destroying its vitality, but more slowly. 
It appears to dissolve all the cancer cells, leaving the vessels to become subsequently 
atrophied, and the firmer structures to gradually gain a comparatively normal con- 
dition. 

" It is a most efficient anodyne, causing an entire cessation of pain in a few days, 
and far more effectually than any sedative that I have ever given. In the cases I 
have described no sedative was employed in any instance, although in some cases 
where great pain had existed previously to commencing the treatment, large doses had 
been given. Whether this arrest of pain arises from the death of the tumor, or, as my 
son suggests, is due to there being no longer irritation of the sentient nerves (in conse- 
quence of tension being withdrawn by the removal of the cells), the fact is the same. 

"If, after the use of the remedy for some weeks, one of these cases were examined 
by a stranger for the first time, he would probably conclude that it was one of com- 
mencing malignant disease, by reason of the irregularities of its surface. The effect 
of the remedy being first to remove the cellular structures, any loss of tissue produced 
by the invasion of the disease cannot be restored, and hence the irregular touch and 
appearance even after cicatrization. The arrest of the hemorrhagic discharge and the 
remarkable freedom from glandular affections, after a lengthened use of the turpentine 



584 CANCER OF THE UTERUS. 

are especially important factors in materially aiding the removal of the cachexia, and 
of improving the general condition of the patient. 

" Without being in position to affirm that the Chian turpentine is a positive cure 
for advanced cancer of the female generative organs, yet, however, the facts here 
adduced may be interpreted in this respect, two circumstances are indisputable — one, 
that all the patients after several months' treatment are living, and that the disease 
has not advanced as is usually the case, but has retrogressed — in fact, has all but disap- 
peared ; and it may at least be safely asserted that when the remedy is steadily used 
for some time it arrests the progress of the disease, and relieves the pain incidental to 
the morbid growth in a manner which cannot be said of any other remedy. It is 
probable that on an extended experience of its use and by variations of the mode of 
administration, it may prove an effectual cure for this intractable disorder. Patience 
and perseverance on the part of the patient and medical adviser are absolutely required. 
We know that in some diseases, as bronchocele and syphilis, a long continuance of 
well-known remedies is often necessary to effect a cure of the particular disorder, and 
that the administration of the remedies has to be varied from time to time, according 
to the therapeutic effects produced by the drugs. In cancer, as far as experience has 
at present indicated, the same alternating method may perhaps have to be employed. 
Whatever may be the ultimate results there can be no doubt that Chian turpentine in 
these disorders is a most valuable medicine. Judging by my experience it is no figura- 
tive expression to say that it acts as a direct poison upon the growth, probably causing 
its ultimate death. In advanced cancer the process of reparation is slow, but if the 
surrounding structures are not too much involved in the process of destruction, it will 
seem that a cure may be reasonably expected. It is not that the remedy has failed 
against the cancer, but that the vital organs are so much destroyed that their complete 
reconstruction and adjustment of functions are not possible, and life fails in conse- 
quence of their mutilated condition. Even under these circumstances, if the cancer 
does not recur, the efficacy of the medicine is obvious. In the early stages of cancer 
it may be affirmed that an undoubted cure may take place speedily, and as the con- 
tiguous structures are not extensively involved, but little deformity ensues ; and experi- 
ence justifies the expectation that under such circumstances a recurrence of the disease 
will not follow. 

" The history of the local treatment of cancer of the uterus is one of singular interest, 
and is highly instructive to the practical physician. The contrast between the general 
and local treatment is the more notable, as nothing can be more injurious to the welfare 
of the patient than an attempt to destroy the cancer by external agencies. The disease 
is not to be averted by this means, as the symptoms assume a more intense and threat- 
ening character, until the patient rapidly sinks. It may be observed that the internal 
treatment here recommended when used for a considerable period is borne by the patient 
with remarkable tolerance. As I have mentioned, in some of my experiments I de- 
termined, in order most thoroughly to test the medicine, to reply upon this alone. 
Kecently the arsenical lotion has been superadded, and with no injurious consequences 
— it appears to act as a disinfectant, and it may produce some benefit by promoting the 
cicatrization of the tissues. Several suggestions offer themselves for inquiry as to aid- 
ing locally the detachment of the growth, after its vitality has been destroyed ; but this 
is not of much importance, as there seems to be no fear of the biood becoming affected 
by the absorption of the decaying tissues, the turpentine probably preventing any such 
calamitous occurrence. 

11 If the practice now described should prove by future experience to be justified, 
then it will be incumbent upon the medical "adviser to treat cancer of the generative 
organs at an early stage of its development, and it is reasonable to conclude that this 
dreaded and most fatal disease will no longer be the scourge it has hitherto proved, 



PALLIATION. 585 

and that another benefit will have been conferred upon suffering humanity by the 
resources of therapeutic art." 

Professor Clay has recently published several cases in which he claims 
a cure by the use of this remedy. 

Palliation. 

There comes a time in the progress of cancer of the uterus that the 
patient is prostrated by the septic effects, caused by absorption of gan- 
grenous products at the surface of the degenerating mass. When this 
is the case we may often relieve the patient more by removing all the 
dead and dying tissue with a sharp curette and thermo-cautery than 
in any other way. To do this the vagina should be dilated with Sims's 
or Simon's speculum until the parts are thoroughly exposed. Then 
with the sharp curette we should gouge out and remove in detail all 
the diseased substance down to the solid tissue of the cervix, and then 
cauterize the whole surface with the thermo-cautery. In this way, for 
a time, we get rid of the hemorrhage, the fetid discharge, and often the 
distressing pain. 

After this the patient's general health will almost always be 
greatly improved, and she will have a happy respite from her terrible 
suffering. 

This operation may be repeated once or oftener, as the conditions 
seem to justify. 

One who has never tried this method of relieving the patient would 
very naturally be deterred from resorting to it by fear that the hem- 
orrhage would be dangerously profuse. A trial, however, will prove 
to him that this apprehension is groundless. If the curetting part 
of the operation is done briskly there will not generally be much 
hemorrhage, and the benefits resulting from it will far exceed the ill 
effects of the loss thus incurred. 

I mention this as the first and most important palliative measure 
to which we can resort, as the comfort of the patient will be promoted 
to a greater extent than by a resort to any other. 

Palliation of the pain, smell, and debility, is the object of the most 
of our treatment. For pain we use local remedies, introduced into the 
vagina. Opium, belladonna, cicuta, hyoscyamus, and Indian hemp, 
may all be used locally. The best form for their application, is that 
of a bolus of five grains of pul. opii. We may instruct the patient to 
introduce the finely powdered opium through a small glass tube, with 
a piston of whalebone and cotton. It is applied thus to the ulcerated 
part and to the walls of the vagina in the neighborhood, and very 
effectually acts as an anodyne. Ten grains of the extract of hyoscy- 
amus may be used as a bolus, or two grains of ext. belladonna ; and 



586 CA3SCEB OF THE UTERUS. 

so on with all the anodynes. A grain of morphia may be mixed with 
the ext, hyoscyam. to great advantage. 

Medicated injections often soothe the diseased part very much also. 
The watery extract of opium may be thrown into the vagina by a 
small svringe, and allowed to remain, the patient lying on her back 
for a length of time. Hydrocyanic acid in solution, gtt. xx to a pint 
of water, passed through the vagina, has a very pleasant effect some- 
times. Injections of vapors of the anaesthetics are highly recom- 
mended, particularly by Professor Simpson. Carbonic acid gas and 
chloroform are those most used. 

The chloroform vapor may be passed through the vagina by the 
ordinary perpetual syringe, made by the Union Rubber Company. 
The chloroform should be placed in the bottom of a large bottle, 
while the receiving-tube of the syringe may be passed through the 
cork and made air-tight with wax. The other end, being inserted in 
the vagina, high enough to almost come in contact with the dise: ise, 
the pumping may be commenced. The vapor will be caused to rise 
in the bottle quite rapidly nnder the exhausting influence of the 
syringe. Care should be taken not to let the tube deep enough in 
the bottle to come in contact with the chloroform, lest this fluid, in- 
stead of its vapor, pass through the instrument. The vapor thus de- 
livered into the vagina causes a sense of heat and glow, which very 
soon seems to replace the pain. "When properly done, patients expe- 
rience great relief frorn this gaseous injection. The same appa:; : - 
will do to convey carbonic acid gas to the parts. The gas is gener- 
ated by mixing in the bottle carb. soda and tart, acid, and then pour- 
ing a little water upon it. Although I have never yet tried the effect 
of great cold to the part. I have no doubt it would be very effective 
in relieving the pain. It should be applied through the speculum 
directly to the parts diseased, and no other. A small amount of the 
freezing mixture, of two parts pounded ice and one part common 
salt, in a small muslin bag, is the means used by Professor Simpson. 
It is thought this cold not only relieves the pain, but that it retards 
the advance of the disease somewhat. The contact should be ::::- 
tinued until the parts assume a pale, bloodless appearance, when this 
is practicable, and may be used twice or three times in twenty-four 
hours. With the local remedies for pain may be mentioned the sub- 
cutaneous injection of morphia over the sacrum, or in the iliac region. 

All local remedies for pain will, after awhile, fall short of the relief 
demanded by our suffering patients, and we will be under the n-r -- 
sity of introducing them into the system in a more effective manner. 
We must resort to their internal use. I need not mention the ano- 
dyne? to which we would resort in such cases ; they are well known 
to the profession. I would, however, caution the student not to use 
opium when any of the others will answer the purpose. Indian 



PALLIATION. 587 

hemp will be found to do this more frequently than any of the others. 
They will all fail, eventually, and opium will prove the great blessing 
in such cases. And let me add the further caution : to commence 
with as small doses as will answer the purpose ; and while we deal 
liberally enough with the drug to get its good effects, increase it 
slowly as possible, for with all our precautions in this respect we will 
be under the necessity of giving it enormously. The anaesthetics are 
too evanescent to be relied upon for main remedies, but they will 
render the influence of opium more prompt, and perhaps lasting. 

The hemorrhage of cancer will sometimes require prompt inter- 
ference. I think, however, that, although the bleeding is always 
ultimately exhausting, it is seldom immediately dangerous from its 
copiousness. I have generally, when the hemorrhage required in- 
terference, depended upon the introduction of small pieces of ice fre- 
quently repeated. It is often very grateful to the patient as well as 
haemostatic. Dr. Simpson recommended powdered tannin introduced 
through the speculum and placed on the part ; but he places more 
dependence on a paste made of perchloride of iron and glycerin. If 
the bleeding should be very alarming, notwithstanding these means, 
the tampon would be our last resort. 

The offensive odor emanating from the disease makes it very de- 
sirable to have some means of correcting it. I should remark, with 
reference to the plans often resorted to, that they are more or less in- 
jurious to the patient and attendant, viz., the burning of sugar, myrrh, 
etc., in the room. This should be done very sparingly. For the air, 
chloride of lime, and good ventilation will do better than all other 
expedients. We do not wish to make a stronger smell less offensive, 
to be sure, but we desire to remove the effluvia. Burnt sugar simply 
fills the room with various other less offensive gases, while we breathe 
with them the original cause of the trouble. Chlorine, disengaged 
from the chloride of lime, probably destroys the material floating in 
the air that offends the sense of smell. But the emanation may be 
lessened by the use of carbolized water as a wash and injection. Fre- 
quent changes of the linen and bedding of the patient are matters of 
cleanliness that, of course, will readily suggest themselves. 

Septicaemia is the condition which most commonly causes the 
greatest suffering and hurries the patient towards a fatal issue. Any 
palliative measure, therefore, which enables us to stay or modify its 
course, will prove a source of great relief. The absorption of the 
liquid products of the necrosed and sloughing tissue eliminated from 
the surface of the ulcer is the cause of the septic fever ; hence a most 
important item in the palliative treatment of cancer is to keep the 
surface of the ulcer as free from dead and fungous substance as pos- 
sible. This may and ought to be done by removing it with the 
sharp curette as often as necessary. When we operate for the re- 



588 



CANCER OF THE UTERUS. 



moval of the necrosed substance and fungus, the parts should be well 
exposed by Sims's or Simon's retractor speculum, the vagina thor- 



FlG. 274. 




Fig. 275. 



Sharp Curette. 



Simon's Curette. 



oughly washed out, and then freely sponged with the tincture of iron. 
This will enable us to see the line of demarcation between the sound 



PALLIATION. 589 

and dead tissue. Then with Simon's spoon every portion of the rotten 
substance should be freely removed. During the operation frequent 
washing away of the blood will be necessary, that we may see what 
we are doing. When the ulceration is extensive, and making its way 
toward the bladder or posterior peritoneal cul-de-sac, it will require 
care to avoid opening one of these cavities. 

Although I have done this palliative operation a great many times, 
I have not seen an excessive loss of blood or any other serious con- 
sequence follow it. It is always better, however, to be prepared with 
means by which to check the bleeding, and probably the best is the 
therm o-cautery. If this, or some other form of cautery, cannot be 
commended, and hemorrhage is sufficient to require an haemostatic, 
a tampon of cotton, saturated with a solution of the persulphate of 
iron, may be advantageously used. 

It is surprising how much relief this little operation generally 
affords. The patient will often be so much improved as to indulge in 
the hope that she is recovering from her loathsome disease. In a 
greater or less time, however, the symptoms will return, and may be 
again relieved by the operation. 

When a case is advancing slowly, this process of cleansing the ulcer 
may be profitably and safely resorted to a number of times. We 
ought not to try to remove any of the tissue beneath the ulcerated 
surface, but confine the operation to the scraping away of the necrosed 
substance. This same operation is applicable to cases in which there 
are frequent hemorrhagic discharges. It generally checks, and some- 
times permanently, losses of this kind, especially if followed by the 
use of the actual cautery or the thermo-cautery. The history of can- 
cer discloses many disappointments in so called cures of this terrible 
malady. The more recent discoveries of this kind are jaborandi and 
the Chian turpentine. The former temporarily tempted the credence 
of the more sanguine of the profession, but after repeated trials has 
been condemned as utterly worthless. 

The Chian turpentine, which, on account of the great respectability 
of its early advocate, seemed to hold out a faint hope that we were on 
the threshold of a valuable discovery, has been found wanting also. 
That the progress of cancerous deposit will ever be arrested by medi- 
cine is a problem for the future. That true cancer of the uterus can 
be cured by any kind of surgical operation is yet to be proven. Can- 
cerous deposit in the uterus, if not the result of blood disease, is a 
focus from which widespread contamination emanates in every direc- 
tion, to an extent that surgery cannot reach. 

Such is the melancholy paucity of our resources in cancer of the 
uterus. Scarce as they are, however, they may afford the sufferer 
great comfort; and we should fall short of our duty if we did not in- 
dustriously employ them, as the best the profession can afford. 



C'HAPTEE XXXVI. 



EPITHELIOMA, CANCROID, EPITHELIAL CANCEE OF THE UTEEUS. 



All these terms, with many others, are applied to a fungoid devel- 
opment in and upon the mucous membrane of the uterus. It is 
essentially an excessive and modified proliferation of the epithelial 
cells, which destroys the membrane upon which it grows, and slowly 
penetrates adjoining structures. 

Its development is not by interstitial deposit, as in other varieties 
of cancer, but consists of superficial accumulations and soft deposits 
of epithelial cells, held together by very delicate connective tissue. 

Fig. 276. 




[Epithelioma of Uterus. 

The shape of the deposit, or growth, varies. In some instances it 
is thinly spread over a large surface, while in others it grows out as 
a fungus from a restricted area. In the former instance the whole 
mucous membrane of the cavity of the uterus may be overlaid and 
permeated by it. from the external orifice to the fundus, and thus be 
converted into a flat, friable covering of the deeper structure; while 
in the latter there may be fungi, of greater or less size, projecting 



EPITHELIOMA — C A NCROI D. 



591 



from the mucous membrane of the uterine cavity ; but much more 
frequently they spring from one of the cervical labia, or the whole 
cervical circle. 

The substance of the membrane thus diseased is generally hyper- 
trophied, but not otherwise very much changed in character, until 
the disease has made great progress on the membrane itself. When 
the disease is situated in the endometrium, the body of the uterus may 
be enlarged for a long time, and not be attached to the other organs. 
When the growth occupies the external membrane of one of the cer- 
vical labia the submucous structure is sometimes increased so that it 



Fig. 277. 




Epithelioma of the Cervix. 



may project into the vagina much beyond its ordinary extent. This 
will give the appearance of a large fungus, while it is really the hyper- 
trophied lip covered with cancroid deposit. At other times the labium 
is not so much enlarged, while the fungus projects down sufficiently 
to partially or wholly fill the vagina. 

In all of these varieties, after a time, the more superficial parts of 
the growth undergo a process of necrosis and slough off. The parti- 
cles thus sphacelated, together with sanguineous and mucous fluids, 
constitute the discharges from epitheliomatous surfaces. 

Disintegration of this sort is generally accompanied with further 



592 



EPITHELIAL CASGEB OP THE UTERUS. 



growth, so that the size of the deposit is not materially, if at all, 

diminished. 

Fig. : -; 




Fungus Growing from the Cervix. 



When the process of disintegration has fairly begun, the disease 
becomes developed, and gradually the role of septic symptoms super- 
venes, and carcinomatous dvscrasia is established. 



Diagnosis, 

The symptoms of epithelioma are the same as in other forms of can- 
cer. They have already been described, and I need not reproduce 
them here. "We may differentiate epithelioma from other forms of 
cancer by examination with the fingei and sound. In epithelioma 
there is an absence of the irregular hardness caused by the submucous 
deposit, by the presence of a soft, friable projection into the vagina, or 



DIAGNOSIS — PROGNOSIS. 593 

the same kind of substance occupying the whole of the cervix, not 
indurated, but somewhat enlarged. When this substance exists in 
the mouth of the uterus, we may ascertain how far it extends by 
passing the sound through it into the cavity. The resistance to the 
instrument will be slight, yet sufficient to impart that feeling of 
resistance caused by its passage through a yielding tissue. If the 
deposit is confined to the cervix the slight opposition to the advance 

Fig. 279. 




Structure of Epithelioma.— From Cornil and Ranvier. 

of the instrument will cease before it reaches the uterine cavity. If it 
extends to the fundus the resistance will continue the whole depth of 
the organ. 

I can imagine, although I have not met with such a case, that a 
polypus in a gangrenous condition might embarrass us somewhat in 
making a diagnosis. The use of the microscope would clear up the 
difficulty in such a case. A very small piece pinched off from the 
mass will suffice for examination. In the disintegrated substance of 
the polypus we find the debris of fibrous tissue, while the cells of 
epithelioma would be found in the malignant growth. If a sarcoma- 
tous polypus should occupy the vagina the microscopic test would be 
equally decisive. 

From a decaying placenta, arrested in the os uteri, we may distin- 
guish the epithelioma by means of the microscope, in case any doubt 
should arise. 

Prognosis. 

The prognosis is not so hopeless as in the other varieties of cancer 
of the uterus, as it is usually localized. In the earlier stages at least 
it is occasionally amenable to treatment. Without treatment it is 

38 



594 



EPITHELIAL CAXCEE OF THE UTERUS. 



equally fatal, as the morbid process is progressive to an unlimited 
extent. 

Treatment. 

The treatment of epithelioma of the uterus, as just intimated, is much 
more promising than the other cancerous affections. The curative 
treatment consists in removing the whole of the diseased tissue, and 
when this is practicable we may reasonably indulge a hope of success. 




Dr. Paqueliu's Thermocautery. 

This can generally be done when the morbid deposit is confined to the 
vaginal portion of the cervix, and sometimes when it extends to the 
fundus of the uterus. The means we possess by which this may be ac- 
complished are the knife, the scissors, the sharp curette, ecraseur, — 
wire or chain, — the galvano-cautery, and the thermo-cautery, or the 
actual cautery. 

I have performed the operation for removing epithelioma by all these 
different instruments separately, and by using several of them in the 
same operation. 

Dr. John Byrne, of Brooklyn, in a very interesting article pub- 
lished in the second volume of the Transactions of the American 
Gynecological Society, advocates the exclusive use of the galvano- 
cautery. He gives a number of cases illustrated by his method of 
operating, and of the success following it. The results are very 
encouraging, and at the time his plan was published it was regarded as 



TREATMENT. 



595 



most promising. He exposed the cervix by his speculum, and ampu- 
tated it with his cautery knife, heated by the battery to a temperature 
that made it assume a dull red color; or, surrounding the cervix, or 
that portion to be removed by the platinum wire, and then applying 
the battery so as to heat it to the same temperature. In doing the 
operation according to the latter method the cervix is fixed by the 
vulsellum, and, if movable, drawn down to a convenient distance 



Fig. 281. 



Fig. 282. 




Byrne's Cautery Battery. 



Byrne's Cautery Ecraseur. 



from the vulva, and the wire, while cold, placed around the cervix as 
high as possible not to include the uterovaginal junction. In this 
position the wire is tightened while cold, and then heated. Before 
heating the wire the constriction should be increased slowly until the 
wire has fairly imbedded itself into the included tissue. 

Quite forcible traction, exerted by the vulsellum, should be main- 
tained while the wire is slowly passing through the substance of the 
neck. This will cause the central portion of the amputated cervix 
to be divided higher than the periphery, and the cavity will be 
conoid in shape with the apex in the centre. If the disease is not all 



596 



EPITHELIAL CANCER OF THE UTERUS. 



removed by this operation the cautery knife may be applied, as dif- 
ferent parts are drawn down by hooks, until the operator is assured 
that all the disease is removed, or that the operation is carried as far 
as the integrity of the bladder and peritoneal cavity will allow. 

The prominent dangers in performing this operation are hemor- 
rhage, wounding the peritoneal cavity, and opening the bladder. The 
first may be avoided by having the temperature of the wire low. If 
it is white hot it will cut the tissues, including the arteries, without 
closing the latter. But if of a dull red heat it will coagulate the 
albumen in the areolar tissue, and the blood in the arteries, some dis- 

FlG. 283. 




Byrne's Cautery Electrodes. 



tance from the wire. In this way the vessels will be sealed and 
primary hemorrhage avoided. To avoid wounding the bladder or 
peritoneum, I am in the habit of applying the wire with the cervix in 
its normal position, and making traction after the wire has been drawn 
tight enough to fix it firmly in its bed. If we are careful to apply 
the wire in this way, there is not much danger of accident. When 
the disease does not extend to the junction between the vagina and 
uterus, this is an admirable method of removing the cervix. The 
objections I make to the galvano-cautery are, that it requires more 
skill in the management of the battery than most practitioners possess ; 
that the burnt surface is so changed we are unable to judge whether 



TEEATMENT. 597 

at the point of separation all of the disease has been removed or 
not ; that it is cumbersome as a portable instrument, and that it is no 
better in any respect and not so manageable as the therm o-cautery. 
I think also that the great heat generated in the vagina is not without 
objection. The advantages are that it destroys the cell growth some 
distance above the surface of the amputated stump, and the opera- 
tion is entirely bloodless. I have not employed it in my recent opera- 
tions. 

In removing the cervix for epithelioma, it will be very convenient, 
however, to have the galvano-cautery, or the thermo-cautery, as one 
of the instruments, but if we intend to thoroughly remove the disease, 
and especially if it extends above the vagino-uterine junction, I think 
we can remove it more safely with the scissors or knife, or both. 

If there is much of a tumor projecting into the vagina, I generally 
apply the ecraseur around it, and include, if possible, the whole of 
the vaginal neck within its grasp. I use the chain instead of the wire 
in the ecraseur because I find it much easier to manage. We should 
be very careful in the adjustment of the chain to avoid injuring the 
bladder or penetrating the peritoneal cavity. In this part of the 
operation the galvano-cautery may be used in place of the ecraseur. 
If we use the ordinary ecraseur, there is no need of dilating the vagina 
with any sort of speculum ; but if we use the hot wire, then the vagina 
should be well dilated by Sims's speculum, Simon's retractor, or Brjme's 
speculum. After as much as possible of the vaginal cervix has been 
removed in this way, the most important part of the operation is just 
begun, because, in most cases we will not be sure of having removed 
all the diseased tissue. The surface from which the neck has been 
thus removed should be examined thoroughly. We can do this best 
by seizing it with the vulsellum or single hooks and drawing it down 
as low as possible, where it can be thoroughly examined. It will also 
insure precision to examine the portion amputated from the cervix to 
ascertain whether any of the diseased tissue was cut through, or 
whether the cut surface is all sound or not. 

If we can assure ourselves in this way that the disease is all removed 
we have little else to do than secure our patient from hemorrhage. In 
my own operations I have had no trouble with any of the arteries 
divided. They usually spirt pretty freely for a few minutes, and then 
gradually cease bleeding. I do not make this statement to encourage 
carelessness as to hemorrhage, because, in exceptional instances the 
hemorrhage is dangerously profuse. Hence, as a precaution against 
hemorrhage, and for the purpose of destroying the cell growth deeply, 
we should apply the cautery at a dull red heat all over the amputated 
surface and be supplied with peroxide of iron tampons. If we find by 
the examination of both amputated surfaces that we have not removed 
all of the disease, or if we have any doubt upon the subject, we should 



598 EPITHELIAL CAJS'CER OF THE UTEETJS. 

seize point after point of the remaining portion of the uterus and cut 
it off with the scissors, and thus excavate the supra- vaginal cervix and 
body of the uterus as high as practicable, or until we are satisfied that- 
all the disease is removed. By the frequent examinations as we pro- 
ceed in this part of the operation, while the whole is held down, we 
can keep within the peritoneal covering of the uterus. In opera- 
ting in this way, we should often introduce the sound to determine 
the direction and depth of the uterine cavity above the excavation. 
The sound will serve as an excellent guide to our progress. If the 
vagina is roomy enough, we may sometimes have the sound held there 
most of the time. After we have excavated to the desired extent, we 
should char the surface of the artificial cavity with the thermo-cautery. 
Dr. H. C. P. Wilson, of Baltimore, has invented an ingenious shield, 
with which the cautery is surrounded, to prevent the heat from affect- 
ing the parts anywhere except at the point of contact, Wilson's shield 
is a very useful addition to Paquelin's thermo-cautery. 

This operation should be repeated as soon as evidence of the return 
of the disease is apparent. Often when the cavity of the uterus has 
been curetted free from the epithelial deposit, that organ contracts, 
and, to some extent, obliterates the cavity formed by the excavation, 
and the area of the disease becomes less each time. In such cases we 
may repeat the operation with more prospect of removing the whole 
of the disease than in the first ; and even the third or fourth opera- 
tion may thus advantageously be performed. Recent experience leads 
me to attach much importance to the very free use of the solution 
of the pernitrate of mercury. Small pellets of absorbent cotton satu- 
rated with that fluid are placed in contact with the scraped surface, 
supported by larger pieces of dry cotton. These large pieces we use 
in such position and in such quantities as to completely protect the 
sound parts, by absorbing the free acid. I am encouraged in this 
recommendation by the fact that epithelial cancer may occupy the 
mucous membrane for a long time without vitiating the substructure 
deeply. 

I prefer this before any other medicine, because it is absorbed and 
acts as a local alterative upon the lymphatics and the juices surround- 
ing the parts. 

Formidable as this operation really is. I have not seen it followed 
by untoward symptoms of any kind. In many cases I have excavated 
the uterus entirely above the internal os until the walls became very 
thin in every direction, and many others to a less extent. Opening 
the peritoneal cavity and bladder is one of the dangers in the progress 
of this operation. This can be avoided by care. Hemorrhage is 
probably the only other danger, and with Paquelin's thermo-cautery, 
or the galvano-cautery, at hand we can easily check it by touching 
the bleeding artery. 



TREATMENT. 599 

The operation may be followed by dangerous shock, primary or 
secondary hemorrhage, metro-peritonitis, cellulitis, or septicaemia. 
For the treatment of all these conditions, except hemorrhage, the 
reader is referred to ovariotomy. 

Injections of carbolized water, sufficient to keep the vagina well 
cleansed, is all that will be found necessary to secure the patient from 
blood-poisoning. 

Ordinarily the cavity is filled up in two or three weeks, and the 
wounded cervix covered with a firm cicatrix. In some instances, 
however, the process of malignant degeneration goes on, and we are 
restricted to palliative measures for the rest of the patient's life. 

The operation of Dr. W. H. Baker, of Boston, is thus summarized by 
him in the eighth volume of the American Gynecological Society Trans- 
actions. After drawing down and fixing the cervix he disects out the 
supra-vaginal portion anteriorly to the level of the internal os, sepa- 
rating it from the bladder with scissors aided by the forefinger then 
proceeding posteriorly working in the same manner in the cellular 
tissue up to the same level. The posterior and anterior incisions are 
then to be united by lateral incisions which prepares the cervix for 
complete removal. " Having done this I cut away the cervix by 
means of the uterotome (or scissors) removing a cone-shaped portion 
from the body of the uterus. It thus becomes possible to remove 
from one-third to one-half of the body of the uterus without cutting 
into the peritoneal cavity or opening the bladder. At this point," he 
he says, " I applied the thermal cautery to the stump at a red heat. 
Applied at a red heat I think we are able to destroy the structure be- 
neath quite effectually. After a thorough application of the cautery 
the patient is put to bed and left undisturbed. We have controlled 
the hemorrhage, and within the space of two weeks the slough comes 
away and we have a clean granulating surface left." Dr. Baker cites 
six cases that have remained cured for five or six years. I have 
operated this way fifteen times, and can count five cures of from four 
to six years' standing. 

Koeberle, in the Nouv. Arch, d* Ohst. et de Gynecologie for ] 886, ex- 
presses himself strongly against total extirpation of the uterus for 
cancer, saying the necessity of it is exceedingly rare. In reading his 
article one would think that he scarcely if at all believed in the pro- 
priety of total extirpation of the uterus for cancer. He says cancer 
of the uterus usually begins in the cervix and extends to the vagina 
and adjoining parts before it reaches above the level of the internal 
os. Primary cancer of the body of the uterus does not often occur, 
and when it exists the cervix is not invaded for a long time. Just so 
long as the diseases in the cervix remains localized, and does not 
extend to the vagina, broad ligaments or the lymphatic glands which 
communicate with the lymphatic vessels of the uterus, so long is the 



600 EPITHELIAL CAXCER OF THE UTERUS. 

body of that organ sound, and it is absolutely useless to remove it. 
On the other hand, in case of primary carcinoma of the body of the 
uterus or of epitheliomic fungosities, etc., of the mucous membrane, 
the cervix being sound, it is useless to remove it. 

Total extirpation of the uterus, whether by laparotomy or through 
the vagina, being admittedly more difficult and more dangerous than 
the removal of either the cervix or body, hysterectomy should be re- 
served for those special cases where partial hysterotomy will not 
suffice for the removal of the entire disease. Abdominal hysterotomy 
— for the removal of the uterus — is applicable to those very rare cases 
in which the disease commences in and is confined to the body of 
that organ, while vaginal hysterotomy is the resort in those more fre- 
quent instances where the disease has commenced in and is limited 
to the cervical portion of the uterus. 

He has performed extirpation of the cervix nine times. In two the 
cancer returned, and in one time enough had not elapsed to decide 
whether it would return or not. He mentions one case of epithelioma 
of the uterine cavity in which he removed the uterus by abdominal 
section in 1875 with no recurrence to date. In 1882 he performed 
successively vaginal extirpation of the cervix and abdominal extirpa- 
tion of the body of the uterus. The patient recovered from the two 
operations, and has not had a return of the cancer. Koeberle's opera- 
tion for cancer of the cervix is essentially the same as that of Dr. 
Baker above described. 

After some observations with the more powerful caustics of potash 
and zinc, I would caution the inexperienced against the introduction 
into the vagina of agents so destructive and difficult to limit. Their 
action may and is likely to extend beyond desirable bounds. There 
can be no question as to the choice between them and the actual 
cautery in some form. The operator can see and control the effects 
of the cautery, and thus limit it to the desired extent, which cannot 
be said of these powerful caustics. The less severe forms of caustic, 
such as the solution of the pernitrate of mercury may serve an excel- 
lent purpose without much danger of too destructive effects. 

I have twice operated by removing epitheliomatous fungus that 
pervaded the whole mucous lining of the uterine cavity, in which 
there has been no return of the disease after four years. With a 
sharp curette I thoroughly and carefully removed the whole of the 
diseased material (after having inverted the uterus in one case), and 
then filled up the cavity with cotton saturated with the solution of the 
pernitrate of mercury. One of the patients was fifty-five years of age 
and the other forty-three. In three other cases operated on this way 
the disease returned ; one within three months, one in about twelve 
months, and in the other the disease did not seem to be arrested. 

In using the solution the cotton should be divided into small pellets 



TREATMENT. 601 

about the size of a Lima bean, saturated with mercury and afterward the 
free fluid pressed out between the smooth surfaces of two pine boards 
and dried. When we are ready to use them they should be secured 
by strong cotton threads so they may be easily removed. After the 
scraped cavity is filled with these pieces of cotton, a large tampon of 
surgical cotton should be passed up to the cervix and the vagina be- 
neath it filled with cotton tampons saturated with glycerin. 

The pernitrate does not destroy the tissues to which it is applied 
very deeply, but I believe it destroys the vitality of the morbid cells 
much beyond its boundary as a caustic. 

The pernitrate dressing may be allowed to remain about twenty- 
four hours, when everything should be removed and the parts kept 
clean by warm water douches twice a day. 

If extirpation of the uterus is justifiable in any form of malignant 
disease it is so in epithelioma, for that disease is often entirely local- 
ized in the uterus, and yet occasionally so situated that we cannot 
remove the whole of it by any other operation. 

The formidable operation proposed by Freund, and practiced by 
him and his followers, has not been followed by a success that would 
encourage me to perform it under any circumstances. We may rea- 
sonably hope, however, that some method of exsecting the uterus 
which will be less difficult of performance and less dangerous in its 
results may be some day invented. Indeed, a long stride in that direc- 
tion has already been made, and is illustrated by an operation recently 
performed by L. C. Lane, M.D., professor of Surgery in the Medical 
College of the Pacific. Dr. Lane terms his operation pervaginal enu- 
cleation of the uterus. That term alone would mislead the reader,, 
for the uterus was not enucleated ; it was extirpated, and the opera- 
tion might very properly be called colpo-hysterectomy, or vaginal ex- 
tirpation of the uterus. 

The operation is very simple, and does not involve the necessity of 
extreme and protracted exposure and handling of the abdominal 
organs. The wounding of tissue is less extensive, and the whole 
operation is done in the lowest and least susceptible portion of the 
peritoneal cavity. 

After placing the patient on her side, in Sims's position, and dilating 
the vagina with Sims's speculum, Dr. Lane had the uterus drawn 
down with Pean's tenaculum forceps, and then made an incision 
through the posterior wall of the vagina. 

"The fundus was then seized by the forceps and the uterus made to revolve on its 
transverse axis, so that the Fallopian tubes and ovaries were brought down low in 
the pelvic excavation in such manner that the base of the tubes and accompanying 
arteries became accessible and easily ligated. 

" Ligation was done with a strong silken cord so passed through button-holes (?) in 
the broad ligaments that they could not afterward slip off. This portion of the opera- 



602 EPITHELIAL CANCER OF THE UTERUS. 

tion was completed in fifteen minutes, but the detachment of the organ from the blad- 
der was long and tedious, but finally successfully done without opening that viscus. 
Yet so thin was the remaining vesical walls that the lustre of the catheter, which 
served as a guide, at times could be seen. The organ being removed the pelvic ex- 
cavation was rinsed out with a one per cent, solution of carbolic acid, a N^laton flexi- 
ble catheter was placed in the bladder, the pelvic excavation was filled with lint, 
saturated with four per cent, carbolized linseed oil, and the abdomen covered with 
india-rubber ice-bags. A drainage-tube was so fixed alongside the carbolized lint as 
to allow the escape of any fluids which should be passed out from the wounded surface. 
" The convalescence was uninterrupted." 

The description of the operation is very imperfect, yet I think it 
will not be difficult for the reader to follow it understandingly. The 
steps of the operation are : 1. The dilatation of the vagina by Sims's 
speculum. I believe Simon's position and retractors would be better. 
2. Fixing and traction of the uterus downward. 3. Incision of the 
posterior vaginal wall, which should be in the central line and extend 
from the cervix to the recto-vaginal attachment. 4. Bringing the 
fundus uteri down through the vaginal opening by vulsellum forceps. 
5. Ligating the posterior border of the broad ligament near the cervix 
uteri, so as to include the Fallopian tubes, ovarian ligaments, and 
accompanying arteries. 6. Separation of the anterior surface of the 
uterus from the bladder. 

The first two steps of the operation need no further description 
than is given in the quotation. In the third step of the operation a 
fold in the centre of the posterior wall of the vagina should be drawn 
forward by the tenaculum, and incised with scissors. The incision 
should be perpendicular with, instead of across, the vagina, and large 
enough to admit the finger, by which we should be guided in com- 
pleting the opening from the cervix to the attachment with the 
rectum. 

What we are to avoid in making this incision is the wounding of 
a loop of intestine or projection of omentum, which may occupy the 
posterior cul-de-sac, and, while dividing low enough, not to wound 
the rectum. The fourth will be facilitated by traction on the cervix, 
which will bring the fundus downward and forward within reach of 
the finger, and then permit the uterus to be retroverted within reach 
of the forceps. Drawing the fundus forward, up well toward the 
pubis, will so twist and condense the posterior portion of the broad 
ligament as to make the fifth step easy of accomplishment. With 
the posterior border of the broad ligament thus brought forward we 
can easily pass the needle containing the ligature from the vagina 
backward, or from behind forward, and secure the arteries with great 
facility. 

Without some caution another danger is that of including the 
ureters in the ligatures. The ureters approach the neck of the uterus 



TREATMENT. 603 

in passing to the bladder, and at the anterior part of the cervix are 
within less than three lines. The ligature, therefore, should not be 
more than one-quarter of an inch from the cervix. 

The most difficult part of the operation is the separation of the 
uterus from the bladder. The fibrous coat of the bladder, where it is 
attached to the uterus, is very thin, and great care is required in sep- 
arating it from the uterus not to open the bladder. The direction 
given by Freund should be remembered. He recommends making 
an incision across the anterior surface of the uterus, through the peri- 
toneum and connective tissue. Then by means of the finger or handle 
of the scalpel, strip the bladder off from the uterus. When the point 
of vaginal attachment to the uterus is reached it may be carefully sepa- 
rated with the knife or scissors. The separation of the neck from the 
vaginal attachment and the side will be easy after the bladder is iso- 
lated. 

It seems to me that the operation of Dr. Lane would have had a 
better conclusion if he had closed the wound either with silk or wire 
sutures. The most of the large opening ought certainly to be closed 
in this way, and if the operation is performed under carbolized spray- 
it would be better thus to unite the whole of it. 

Czerny* the reviver of vaginal hysterectomy operates similarly, ex- 
cept that he begins by incising the vaginal wall around the cervix, 
and separates the bladder from the uterus before opening the sacro- 
uterine pouch. The fundus is then turned back and brought out 
through the opening, the peritoneum then opened at the anterior 
uterine wall, the broad ligament ligated and the uterus cut out between 
them. 

Olshausen removes the uterus without retroverting it. He draws 
down the cervix, cuts through the vaginal wall all around it, and sepa- 
rates the bladder and rectum from the uterus with the finger. The 
bleeding is then completely checked, the cervix drawn down until the 
broad ligaments are felt to be put upon the stretch, the peritoneum 
punctured with scissors, and the opening enlarged with the fingers. 
An elastic ligature is then passed over the left broad ligament by means 
of a hook, shaped like an aneurism needle, the ligature tied, and the 
broad ligament severed between it and the uterus. The same is then 
done on the right side. 

Leopold (with three deaths in forty-two cases) operates similarly 
but ligates the broad ligament in sections, beginning below and includ- 
ing the peritoneal coats. 

Peter Mueller made the operation easier by cutting the uterus in 
two halves by a median longitudinal incision with blunt pointed 
scissors or knife. The bleeding may be controlled by compressing 

* Lehrbuch d. Frauenkrankheiten. F. Winckel. 



604 EPITHELIAL CANCER OF THE UTERUS. 

the uterine halves, while the broad ligaments are carefully tied in sec- 
tions. 

Fritsch, whose statistics are unusually favorable, incises first the 
lateral vaginal fornices and separates the uterus above the uterine 
artery. After checking all hemorrhage he unites the lateral incisions 
by transverse ones in front and behind, ties a rubber ligature tightly 
around the cervix in the incision, loosens the bladder from the uterus, 
and after drawing the cervix well downward and backward, pulls the 
fundus forward and out through the vesico-uterine opening. The 
broad ligament is ligated from above downward. 

Winckel* recommends, as a farther improvement, the cutting out 
of the uterus in a spiral manner. He begins his incision in the 
anterior vaginal fornix, carries it around the cervix and deepens it 
gradually as he goes around and around. Each vessel is tied as it is 
cut, and the uterus is pulled down as it becomes loosened. The peri- 
toneum is easily opened, both before and behind, when thus reached, 
and the broad ligaments can then be seen and tied in portions. 

When the tubes and ovaries can be readily drawn down they should 
also be removed, as they may contain germs of the disease. 

The vaginal edges when not closed by sutures are merely drawn 
together and supported by a vaginal tampon of iodoform gauze (ten 
per cent.). The tampon may be left in place for six or eight days, 
but the vulval dressings must be changed frequently on account of 
the sero-sanguineous discharge that occurs on the first days after the 
operations. Antiseptic vaginal douches are used after the tampons 
are removed. 

, Pean and his followers use hemostatic forceps instead of ligatures 
for the control of the hemorrhage. After opening the abdominal 
cavity the fundus is brought down and out of the posterior or anterior 
opening (as may be the easier) the whole ligament clamped in a single 
long pair of forceps and severed between the forceps and the uterus. 
If one pair is not large enough, or fails to prevent bleeding, one or two 
more may be applied. If the fundus cannot be brought down suffi- 
ciently a pair may be applied to the base of each broad ligament, the 
cervix cut loose as high as the instrument reaches, and the fundus 
then turned down and the remainder of the ligaments clamped from 
above. Curved forceps are sometimes used for the latter purpose, for 
they do not require the fundus to be so completely turned out. Bleed- 
ing vaginal edges may also be clamped by forceps. At the end of 
forty-eight hours the forceps are all removed, and the antiseptic tam- 
pons in two or three days afterwards. After this the vagina is gently 
irrigated two or three times a day and antiseptic dressings applied to 
the vulva and vaginal entrance. 

* Op. cit. 



TREATMENT. 605 

This method seems to be a decided improvement upon the others, 
since it enables us to operate more quickly and therefore with less 
shock and less danger to the patient, and also with less danger of 
hemorrhage. Hemorrhage and shock are the chief immediate dan- 
gers, sepsis and inflammation the principal remote ones. Occasionally 
it may be better to use both ligatures and the hemostatic forceps ; the 
former for the cut vaginal edges and small bleeding surfaces, the latter 
for the main parts of the broad ligaments and such extensive bleeding 
surfaces as can be gathered into the jaws of one pair. 

Should we desire to amputate the body from the cervix this method 
of bringing the uterus out of the peritoneal cavity would give us an 
excellent opportunity with the minimum risk. 

Redner explains how the favorable results in ovariotomy led also 
to the removal of myoma and carcinoma of the uterus by laparotomy, 
and then how more recently the unfavorable results of the method of 
operating advocated by Freund led to a neglect of laparotomy. This 
change was favored also by the fact that the large number of cancers 
springing from the cervix uteri could only be removed imperfectly 
and with difficulty by this method, hence we have drifted back to the 
older practice of attacking the organ through the vagina. Redner 
himself operated several years ago in twenty-eight cases of carcinoma 
uteri through the vaginal wall, with almost invariable success (only 
three deaths, two by infection, one by hemorrhage), by supravaginal 
excision of the cervix. And once having gone so far it was but a step 
to remove the whole uterus through the vagina. 

The prognosis is not only considered good by Schrceder* because the 
mortality figure is so small, but also because the convalescence is so 
rapid and easy, for in the cases cited only two showed slight fever, 
and two others mild symptoms of collapse. 

As to the indications for such operative measures, Schrceder advises 
against interference when the cellular tissue of the pelvis is already 
invaded by cancer, which must be determined by careful palpation. 
He further calls attention to the fact that the* larger the diseased 
uterus the greater will be the difficulties by this method, and the more 
appropriate will Freund's procedure become, and, at the same time, 
that in cases of cancer of the cervix situated low down we should be 
more conservative in either enucleation or supravaginal incision ; yet 
after all, notwithstanding all of the advantages of the new procedure, 
the former methods would still retain their merits, according as they 
might be selected in particular cases. 

* Paper read by Schroeder (Berlin) on "Total Extirpation of the Uterus per 
Vaginam " in the gynecological section of the fifty-third Versaramlung der dentsche 
Naturforscher und Aertze in Danzig, in September, 1880. Keported in the Archives 
fur Gynacologie Sechszehnter Band, Drittes Heft. 



606 EPITHELIAL CAKCER OF THE UTERUS. 

In Martin's three cases he found such difficulty that in only one 
case was the operation complete. 2d case : Impossible to sever all 
adhesions; portion of diseased tissue remained behind. 3d case: Same 
kind of difficulty ; conclusion that firm adhesions and brittleness or 
friability of the uterus contraindicate the operation. 

Interrogated by Meyerbeer, Schroeder says he closes the vaginal 
opening with curved needle and silk, but recommends ligation of 
ligaments by wire. 

Baum (of Danzig) says he formerly operated successfully by supra- 
vaginal incision seven times, without resulting fever, that in only 
two eases had he failed to find a return, but in the last few months 
had operated per vaginam four times, two of the cases resulting in 
death from shock and septic peritonitis. He operated after Billroth 's 
manner, and in one case removed the ovarian tubes, but applied no 
sutures in order to allow better drainage of the secretions. A drain- 
age-tube was introduced, through which, in case of fever, the parts 
were washed out. 

Schroeder favors sutures which do not render septicaemia more 
liable, and insure against protrusion of intestines. 

Baum prefers his method, and thinks protrusion of intestine can be 
prevented by position. 



CHAPTER XXXVII. 

SARCOMA. 

Another variety of malignant disease of the uterus is sarcoma. It 
generally shows itself in the form of a tumor, developed at the expense 
of the fibrous structure of the uterus, an apparently isolated portion 
of which is infiltrated by an abundance of peculiar cells. 

While not encapsulated, like the fibrous tumors, these growths dis- 
place the surrounding tissue, and protrude in a submucous or sub- 
serous direction until they become, to a greater or less degree, 
pediculated. When first discovered and described these tumors were 
denominated recurrent fibroids, because ablation did not destroy them. 
Their recurrence is, doubtless, due to the fact that, while apparently 
isolated, the neighboring tissues are permeated by the sarcomatous 
cells. Instances of diffuse sarcoma are also sometimes met with when 
all the tissues of the entire uterus are infiltrated. 

The cases of diffuse sarcoma with which I have met have all 
belonged to the small-celled variety, and the process of degeneration 
has spread from the uterus to the surrounding tissues, invading espe- 
cially the connective tissue of the broad ligament. Sarcoma is a less 
frequent disease than carcinoma or epithelioma. 

Symptoms. 

Its early clinical history is very similar to that of the fibrous tumor, 
and is more generally mistaken for it than any other growth. Serous 
leucorrhoea, metrorrhagia, and enlargement are the main ones. Its 
course is usually rapid, less so, perhaps, than cancer, and more so 
than fibrous growths. In some cases it attains to a large size before 
any peculiar phenomena appear. After a time, especially if sub- 
mucous or polypoid, it begins to break down, the discharge becomes 
offensive and copious, and the disease proves fatal in much the same 
way as cancer. 

The general symptoms in the early periods of development are not 
marked, and they only become so after the tumor has grown large 
enough to interfere by pressure with the fecal and urinary excretions, 
or in breaking up furnish septic material in such quantities as to 
induce septicaemia, when all the disastrous symptoms of that formid- 
able fever are established. Thus diarrhoea, copious perspiration, ele- 
vated temperature, rapid pulse, failure of the assimilative functions, 
and great nervous prostration tend to a fatal issue with as much cer- 
tainty as any other of the malignant affections. 



608 



SARCOMA. 



Diagnosis. 

In the commencement it is always difficult to arrive at a correct 
diagnosis. The symptoms are not characteristic, and until the com- 
mencing dissolution of the tumor are as much like those of fibrous 
tumor as they are like carcinoma, and when disintegration begins they 
thoroughly simulate cancer or epithelioma. The only sure diagnostic 
sign of sarcoma is afforded by the microscope. A portion of the tumor 



Fig. 284. 




Structure of Sarcoma.— From Cornil and Ranvier. 

should be submitted to microscopic examination, when the character- 
istic cell may at once be discovered (Fig. 284). 

Mr. Butlin* makes the following histologic distinction between sar- 
coma and carcinoma. He says : 

" I should then define carcinoma to be a tumor of epithelial origin, having generally 
an alveolar structure, and sarcoma a tumor of connective-tissue origin, formed gener- 
ally of embryonic tissues, and without alveolar structure. And, for the minor differ- 
ences, the cells of carcinoma generally resemble those of the epithelium from which it 
grows ; there is little intercellular tissue ; the vessels run in the fibrous tissues, not 
among the cells ; and multiplications of cells is by endogenous formation. On the 
other hand, sarcoma is composed of round or fusiform or giant cells, and these are 
packed, in a more or less abundant basis ; the vessels are often mere fissures between 
the cells, and the cells increase in number by division. These minor characters are 
common, but they are not constant. One or other of them may be absent in a tumor 
of either class; or, worse, may be present in a tumor of the other class. More com- 
monly it is sarcoma, which simulates the appearance of carcinoma ; but, fortunately, 
this feigning takes place most often in textures where there can be no question of the 
origin, and therefore of the nature, of the tumor. The alveolar structure, found in 
some sarcomas, is rarely so perfect as that of most epithelial tumors ; indeed, careful 
study discovers that the tissue which surrounds the alveoli is generally formed of spin- 
dle cells. There is, in most cases, no real difficulty in assigning each tumor to its 
class." 

* Lectures on the Kelation of Sarcoma to Carcinoma, by Henry Trentham Butlin, 
F.R.C.S. American reprint. London Lancet, February, 1881. 



PROGNOSIS — TREATMENT. 609 



Prognosis. 

The prognosis is no more favorable than that of cancer. While in 
many instances the tumor caused by the morbid growth seems to be 
quite isolated, the cells penetrate the surrounding tissue to such an 
extent as not to be eradicable. 

The contamination of the surrounding tissue does not seem to take 
place by absorption and transmission of the cells, or debris of the 
sarcomatous cells, but to be due to the insinuation of the cells into 
the contiguous substance surrounding the growth. It is, probably, 
always local in its origin and progress. This consideration, if true, 
would encourage us to hope that, by ablation of all the morbid sub- 
stance, we might arrive at a cure. 

Treatment. 

To be radical the treatment should consist of the entire removal of 
the growth. When the disease is confined to the uterus, I think the 
most rational treatment would be the removal of that organ. Hys- 
terectomy would seem to me to be more promising in sarcoma than in 
carcinoma. 

In addition to the general palliative treatment, detailed under the 
head of cancer, the removal of sloughing masses by the curette and 
scoop, we will often derive great benefit from the free administration 
of ergot. The contraction of the uterus, under the influence of ergot, 
will do more to clear out the softening mass from its cavity than any 
instrumental interference. I have in several instances removed the 
sarcomatous growth by ergot so thoroughly that the improvement of 
the patient's health led them to hope for ultimate recovery. When 
the growth is submucous, and of the most friable variety, I would 
fully expect it to be expelled by ergot. It does not, however, affect 
the spread of the growth, and ultimate fatal result. 



39 



CHAPTER XXXVIII. 

TUMOKS OF THE UTERUS. 

Any organized growth within the substance of the uterine walls, or 
depending from or connected with any of its surfaces, may be called 
a tumor. This definition will include polypi of all varieties and sizes, 
from the tn ere granule that renders the mucous surface irregular by 
its protrusion, to the growth which fills up the uterine cavity. 

Fibrous Tumors. 

Fibrous tumors of the uterus are homologous growths. They are 
not pure hypertrophies of certain parts of the uterine tissues. As 
proof of this the tumor-tissue exhibits too much of the rudimentary 
character of fibres of the undeveloped kind, and there is not a uni- 
form proportion of the different constituent elements. For instance, 
we find that some specimens are quite firm and resisting, while others 
are frail. In the firmer variety, the fibrous element is more abundant 
than the connective, and these ought to be denominated myomatous 
or muscular fibrous tumors, while the term fibroma would be better 
adapted to those tumors in which the fibres of the connective tissues 
preponderate, and the tumor is softer. 

The question very naturally arises : How do those tumors origi- 
nate? a question that cannot be satisfactorily answered. What we 
know about their " habits " I will lay before the reader. They occur 
more frequently in persons between the age of thirty-five and fifty, 
and are found oftener in women of African descent than in those of 
European or Asiatic origin. From much observation I am also per- 
suaded that the long continuance of great hyperemia of the uterus 
strongly predisposes patients to fibrous tumors. Hence, w T e find them 
connected with sterility, dysmenorrhcea and menorrhagia. I know 
that these conditions are often the results of fibrous degeneration, but 
I have had opportunity of watching many such morbid states of the 
uterus, which, while giving rise to other symptoms, were constantly 
attended with hyperemia. In some such cases after years of suffering 
tumors were developed. One remarkable instance is in a patient w T ho 
has been under ni}* eye for fifteen years. She is a maiden lady, now 
forty years of age. A few years after she commenced to menstruate, 
she became subject to hyperesthesia and hyperemia of the uterus. 
Although I saw her, and made examination of the uterus several 
times a year during these fifteen years, I discovered nothing which 



FIBROUS TUMORS. 



611 



induced me to suspect fibrous growth until three years ago. Then I 
could easily make out a tumor, with two nuclei of development in the 
anterior wall of the uterus. When first noticed, the tumor was half as 
large as an orange. It grew to four times that size in the next twelve 
months. I have seen so many cases similar to this that I cannot be- 
lieve hyperemia and the development of the tumor to be a mere coin- 
cidence. We know that prolonged hyperemia is one of the necessary 
conditions of hypertrophy, and it is hardly possible to have hyper- 
trophy without hyperplasia. It would seem, indeed, to be the hyper- 
trophy of the vortices or foci of muscular gyrations in the undeveloped 
condition of the fibrous structure which leads to the formation of 
these tumors. 

All fibrous tumors of the uterus have their origin in the wall of the 
organ. Some arise immediately in contact with the mucous mem- 

FlG. 2S5. 




Origin of Fibroid Tumors. 

brane, then begin to intrude themselves into the cavity of the uterus 
as soon as they begin to grow, and become pediculated while yet 
small, d. Others commence their growth beneath a very thin layer of 
fibres, A. These are quite near the mucous membrane, but not in 
immediate contact with it. They ver}^ soon overcome the resistance 
of the thin layer of fibres, and pushing the mucous membrane before 
them, become pediculated later in their growth. If, however, they 
are deeper in the wall, but nearer the mucous than the serous surface, 
the larger part of their bulk encroaches gradually upon the interior 
of the uterus, forming broad tumors that fill the cavity. They can 
easily be recognized by the ringer after dilating the cervical canal. 



612 TUMORS OF THE UTERUS. 

All of these varieties are submucous tumors, but in common profes- 
sional language the first two are called polypi, while to the last the 
term submucous tumor is generally given. The term intramural is 
used to indicate the tumor that arises in the centre of the uterine 
wall, b ; a tumor which in its development displaces the surrounding 
tissues alike in every direction. In point of fact the exact central - 
mural tumor is very rare, the great majority having their nidus ex- 
ternal or internal to the central layer. The subserous tumor varies 
in its relative distance from the peritoneal surface in the same manner 
as the submucous from the lining membrane of the uterus. Hence, 
some of them spring from the outer surface of the uterine wall, are 
suspended by a very slender pedicle, and covered only by the peri- 
toneum, e. Others are not so pendulous, but still are enveloped by 
only a very thin layer of fibres externally. If they are still more 
remote from the peritoneal surface, they merely show themselves as 
bulky protuberances on the outside of the uterus, c. One more state- 
ment with reference to position. They are usually developed in the 
wall of the body, and comparatively seldom have their origin in the 
cervical portion of the uterus. This statement is true of every variety. 

Their Nature. 

A dissection of these tumors enables us to discover that they are 
surrounded in most instances by a well-marked capsule. It ought 
not to be called a cyst for it has not a separate organization, and it is 
formed by the tissues surrounding the tumor, being compressed as 
they are displaced, until the inner surface of the cavity becomes 
smooth. At a number of points the capsule and surface of the 
growth are connected by frail fibrillse and vessels. The number and 
magnitude of these connecting fibres and vessels vary, but it is ex- 
ceedingly uncommon for vessels of considerable size to enter any of 
these tumors, and the vascular supply is proportionately small. From 
these facts the logical deductions, namely, that fibrous tumors of the 
uterus are of slow growth, of low vitality, and not usually reproduced 
from their capsule, are corroborated by observation. The source of 
their nutrition, or their vascular supply, is diffuse, coming through 
many small channels at various points in their periphery, and not, as 
in the ovarian tumors, from one great artery. Such a supply is the 
cause of a somewhat definite period of vitality. It is not capable of 
maintaining the growth to an indefinite degree, and a disturbance of 
its nutrition may easily occur. Thus, after they attain a certain 
magnitude, they are likely to stop growing, and in many instances 
they degenerate into a lower form of tissue, resembling cartilage, or 
even to descend still lower in the scale of vitality, and be partially 
changed into a cretaceous deposit. Again, their low vitality subjects 



NATURE OF FIBROUS TUMORS. 613 

them to the process of inflammation or eremacausis. Inflammation, 
resulting in gangrenous disintegration, is one of the accidents that 
sometimes brings about their discharge and cure. At other times it 
occasions the death of the patient during the complicated consequences 
thus arising. I have witnessed both of these terminations. The 
fibrous tumor of the uterus is frequently multiple. 

The position occupied by the growth is accompanied by a number 
of important effects. When situated in the centre of the wall — intra- 
mural — it grows more rapidly than when in the subserous portion of 
the fibrous structure, but probably not so vigorously as when nearer 
the mucous membrane, or when it belongs to the submucous variety. 
In fact, it will generally be found that the nearer the peritoneum the 
nucleus of origin, the more slowly will the tumor increase in size. 
We also find that the intramural and submucous varieties cause the 
uterus to grow and become vascular with much greater certainty than 
the subserous. Indeed, we often find very large subserous tumors 
growing from a uterus of comparatively small dimensions. The 
tumor may be not less than ten times the size of the organ to the fun- 
dus of which it is attached. If a tumor of this size were developed in 
the centre of the wall of the body of the uterus, the depth of the cavity 
would be not less than six inches. While the uterus in such cases is 
more than ordinarily vascular, it is not so much so as it would have 
been if the tumor had belonged to the intramural variety. Of course 
the polypus, or submucous tumor, develops the uterus with more 
uniformity than the intramural variety. The uterus, in the cavity of 
which there is a polypus, grows with nearly the same symmetry as if 
pregnant. 

It logically follows from these facts that the submucous and intra- 
mural varieties are the most mischievous, as the more rapidly the 
uterus grows, the more certainly will it do mischief by pressure ; and 
the more vascular the uterus becomes, the more hemorrhage will 
occur. And we find from observation that these inferences are cor- 
rect. 

Again we find that developed in certain zones of the organ their 
behavior and effects are different. Fibrous tumors comparatively 
do not often originate in the cervical portion of the organ, and when 
they do their growth is not very rapid, nor do they cause the uterus 
to become very large. In the corporal zone they grow most rapidly, 
cause the uterus to enlarge faster, and do more mischief. Lastly, in 
the fundus their activity of growth is less rapid, and produce less 
morbid changes upon the organ. 

In examining uteri containing fibrous tumors, which have fallen 
under my observation, I have noticed that the character, as well as 
the degree of development, has varied quite considerably. 

The growth of the fibrous structure of the uterus is not exactly the 






614 TUMORS OF THE UTERUS. 

same in character and degree as in pregnancy. The fibres are cer- 
tainly enlarged, and they become muscular, but in very few localities 
do they attain to the same perfection as in pregnancy. 

In the subserous variety they do not anywhere attain to the per- 
fection of pregnancy, and are usually quite rudimentary in their 
character. Nor do they possess much contractile power. In the in- 
tramural tumors the fibres surrounding the growth attain much 
greater dimensions, and acquire great power. Seldom, if ever, how- 
ever, do they assume all the qualities of the fibres in the gravid uterus 
at term. In these cases the fibres in the opposite wall do not keep 
pace with those surrounding the tumor. In the submucous variety 
the fibres external to the tumor in the same side in which they origi- 
nate are largely developed, while those between the tumor and mu- 
cous membrane attain considerable length, but are attenuated, and 
lack strength. This is one reason why they are pushed into the cavity 
of the uterus. 

When the tumor is polypoid, and occupies the cavity of the uterus, 
especially if it comes from the body near the fundus, filling up and 
distending the cavity of the body in every direction, it causes great 
uniformity of development of the fibres. The fibres all around grow 
more as they do in the pregnant uterus, attain great power, and usually 
expel the growth into the vagina. 

Very nearly the same statements may be made in reference to the 
growth of the vascular system in the different varieties of tumors. 
The vessels are more enlarged on the side occupied by the tumor in 
the intramural and subserous than on the unoccupied side. They are 
more generally enlarged in the intrauterine polypus. 

It may be further stated that a single tumor grows more rapidly, 
causes greater vascularity in the uterus, and brings about greater 
hypertrophy of the fibres of the uterus than the multinuclear form. 
Indeed, were numerous points of growth to commence at the same 
time, although great bulk may be attained, the bulk consists in the 
morbid deposits more than in the growth of the physiological struc- 
ture of the uterus. This is so markedly the case that after a certain 
time this kind of tumor stops growing for the want of vascular sup- 
ply, and becomes transformed into a dense tissue of a vitality far below 
that in the single tumor. It sometimes becomes a true fibroid degen- 
eration of the whole uterus, in which it would be hard to trace any of 
the anatomical elements peculiar to that organ. 

Symptoms. 

From this exposition of the growth and effects of tumors upon the 
surrounding structures, it will be readily inferred that the symptoms 
observed in connection with fibrous tumors of the uterus are not 



SYMPTOMS. 615 

the same, and must vary greatly in the different varieties. The most 
frequent symptom is hemorrhage, either at the time of menstruation 
or during the intervals. In the early periods of the growth the pa- 
tient will observe profuseness in the menstrual flow, and some cases 
occur in which this is the only time when there is loss of blood, but 
in very many instances the losses take place at irregular intervals, 
and sometimes the discharge is so irregular that the patient will lose 
her knowledge of the time when she ought to be unwell. In quite a 
large proportion of cases there is no deviation from the ordinary habit 
of menstruation. The patient is regular. 

The variations of this hemorrhagic symptom conform, in general, 
to well-known conditions, and we may expect to find the hemorrhage 
more profuse the nearer the tumor is situated to the mucous mem- 
brane. In hemorrhagic cases we shall also find that the size of the 
tumor has much to do with the flow. The larger the tumor, other 
things being equal, the greater the hemorrhage. Large submucous 
tumors will, therefore, cause more profuse hemorrhage than any other 
sort. In estimating the value of the rule in the correspondence of 
these conditions, we must remember the frequent coexistence of small 
submucous with large subserous tumors, and that, as there are excep- 
tions to all rules, we may sometimes have profuse hemorrhage in sub- 
serous, and small losses in submucous tumors. The latter exception, 
however, is very rare. 

Leucorrhcea, consisting of thick, tenacious mucus, from the cer- 
vical cavity, is perhaps the next most frequent symptom, and it is 
generally governed by the same rules with respect to frequency and 
profuseness as metrorrhagia, being greater in quantity in submucous 
than subserous tumors. 

Watery discharges from the uterus are also a common and signifi- 
cant symptom. They occur more frequently just after, and appear 
to be supplemental to, the hemorrhages ; and I must observe with 
reference to them, also, that they are usually more profuse in sub- 
mucous tumors. It will be observed that all the discharges — hem- 
orrhagic, leucorrhceal, and watery — show themselves under the same 
circumstances, and there is a very good reason for this, which I men- 
tion in passing. The cases in which the tumors are so situated as to 
greatly increase the vascularity of the uterus, are also the cases in 
which these discharges are more profuse. 

Dysmenorrhea is not so commonly met with as the three symp- 
toms already mentioned. When it does occur it is of the obstructive 
variety. It is manifested by cramping pain recurring at intervals. 
We may account for its assuming this phase by the fact that the tumor 
encroaches upon the cavity of the uterus and renders it tortuous, and 
in some cases occludes it by forcibly pressing the sides together. The 
blood is accumulated above these obstructed places, and the pains 



616 TUMOES OF THE UTEETJS. 

are caused by the efforts of the uterus to expel the blood thus im- 
prisoned. 

The subserous tumor is the only kind that may not occasionally 
cause dysmenorrhcea. It is probably more frequently present where 
there is a number of nuclei of development, some of them being sub- 
mucous. 

Among other symptoms. I wish particularly to call attention to 
that of pressure. It begins very early in the progress of these growths, 
and is quite often noticed. The first evidence of pressure is suffering 
in the pelvis. When the tumor first becomes enlarged, the uterus 
presses upon the perineum, and this pressure causes a feeling of un- 
usual weight in that region. This " bearing-down sensation " may 
increase until, finally, the uterus and vagina may protrude through 
the vulva ; the womb may also fall backwards upon the rectum and 
produce tenesmus or other uneasiness in that organ ; and not unusu- 
ally hemorrhoids are thus developed with their attendant symptoms. 
Should anteversion occur, the bladder will suffer from the pressure 
in the various forms of dysuria, and even inflammation in that viscus. 
When the tumor is located in the posterior wall, the uterus is retro- 
verted ; when in the anterior, it is anteverted. When the organ is 
enlarged equally in all directions, it will be prolapsed. As it enlarges 
so as to fill up the pelvis, the pelvic veins are sometimes so pressed 
upon as to retard their circulation, and there may arise varicosity in 
the legs, anus, vulva, and surrounding parts. The nerves suffer from 
the pressure in such a way as often to manifest sciatica, and crural 
and vulvar neuralgia. 

When the tumor is large enough to rise out of the pelvis, it may 
cause pressure upon the abdominal viscera, and by its bulk, hardness, 
and irregular shape give rise to great inconvenience from distension 
of the abdominal cavity, producing more suffering than the same dis- 
tension from most other causes. 

Several important complications are likely to result from pressure, 
such as inflammation of the pelvic viscera, cystitis, rectitis, cellulitis, 
and local peritonitis. I need not stop to give the symptoms of these 
complications, as they are the same as when arising from other causes. 
The pelvic inflammation sometimes extends to the veins passing 
through the cavity, and gives rise to phlegmasia alba dolens. 

Abdominal inflammations also complicate these cases, some forms 
of peritonitis especially. A moderate peritoneal inflammation may 
result in serous effusion, and the ascites sometimes gives rise to more 
trouble than the tumor, being in some cases the immediate cause of 
the fatal result. 

The consideration of the effects caused by pressure exerted by these 
tumors leads me to the subject of their progress and development. 

It may be said of them, in a general way, that their growth is slow. 



DIAGNOSIS. 617 

This is especially so as compared with most other growths. In very 
many cases it requires years for them to attain a magnitude sufficient 
to endanger the patient's life. Indeed, some patients carry them 
through a long life without experiencing more than a slight incon- 
venience. Occasionally exceptional instances occur, however, in which 
the growth is rapid and very destructive. 

The conditions which promote their growth are now pretty well 
understood, especially the general proposition : that the more vascu- 
lar the uterus becomes from any cause the more rapid their growth. 
The converse of this statement becomes a necessary corollary. 

They grow rapidly during pregnancy. During the period of life 
in which the menstrual discharges occur in a normal way, the tumor 
grows more rapidly than after the menopause. The submucous in- 
crease in size with more rapidity than the subserous, and the tumor 
centrally located in the uterine wall generally requires for its devel- 
opment a period of time which may be regarded as a mean between 
the other two. The multiple ones advance more slowly than the 
single tumors. There is one circumstance which may add greatly to 
the vitality of any of these growths, and consequently cause them to 
grow with great energy. I allude to adhesions to the visceral or 
parietal peritoneum. When extensive adhesions occur, the vessel of 
the adherent surface penetrates the uterine tissue and greatly increases 
its vascularity. This is so remarkably the case in rare instances, that 
the peritoneal surface of the tumor becomes reticulated with large 
vessels. The growths thus usually become very formidable. Occa- 
sionally, tumors that have grown so slowly as to seem stationery in 
this respect, suddenly start up, and their behavior is entirely changed. 
We see this in subserous tumors in a remarkable manner. It is 
hardly necessary for me to remind the reader that this change is 
generally preceded by inflammation, and that this is the cause of 
adhesions. 

When the tumors, as sometimes happens, undergo interstitial de- 
generation in such a manner as to cause cavities in their substance, 
they grow rapidly by an accumulation of fluid in these hollow spaces. 
This change constitutes a new variety, which is called fibro-cystic. 
They often become very large, grow very rapidly, and are mistaken 
for ovarian tumors. Some of our most expert specialists have been 
betrayed into their removal under this misapprehension, and have 
sometimes been made aware of their mistake only after a careful 
examination subsequent to their extirpation. 

Diagnosis. 

We learn, after much observation, that the history and symptoms, 
although very important items in the diagnosis, are not sufficient to 
establish it, hence we are obliged to resort to physical examination. 



618 TUMORS OF THE UTERUS. 

Another observation may be made in this connection ; the greatest 
difficulties in forming a correct diagnosis will be experienced in 
tumors of each extreme in size. The medium-sized tumors may be 
diagnosed without much trouble. In cases of small-sized tumors we 
cannot always determine without much care whether the enlargement 
of the uterus is clue to a tumor or some other cause. In such cases 
the depth of the uterus should be measured by the sound. While 
the sound is in the uterus, and that organ held in its normal posi- 
tion, the finger is to be passed as high as possible into the rectum, 
and the posterior wall thoroughly explored. If there is a tumor in 
that part it will be found thickened and nodulated. Should this not 
be the case a male catheter should be introduced into the bladder, and 
the anterior wall of the uterus carefully surveyed. If the symptoms 
are sufficiently grave to excite apprehensions, and yet leave an un- 
certainty, the finger may be passed into the bladder instead of the 
catheter ; otherwise it should not be used. 

To ascertain the existence of a small intrauterine or submucous 
growth the cervix should be dilated with sea-tangle, or compressed 
sponge-tent, until the finger can be passed into the cavity of the body, 
when there will be no difficulty in finding the tumor. None of these 
proceedings are justifiable, if there is tenderness or other signs of 
general inflammation of the uterus. 

It is more frequently the case that the tumor is evident, and then 
the object is to ascertain if it is uterine. To determine this question 
it is necessary to discover its attachments. This may be done placing 
one finger on the mouth of the uterus, and another in the rectum to 
move the tumor. If it is attached to the uterus they will move 
together. We should be careful, in making this kind of an examina- 
tion, to make the movements vary in direction , if possible, the tumor 
should be moved from the uterus, or upward, or downward. The 
tumor ought to carry the uterus with it when moved in any direc- 
tion. If the sound is passed into the uterus, and the tumor moved 
afterwards, the instrument, as may be seen, will very plainly indicate 
the movement of the organ. The cavity will also be increased in 
length. When a tumor is large enough to be felt above the pubis the 
attachment will be more easily made out by moving it with the 
hands pressed upon it from above, while the sound is in the cavity, or 
the finger on the cervix. 

The second most important diagnostic indication is the firmness of 
the tumor. The fibrous tumor is usually hard and not elastic. An- 
other almost essential circumstance has just been alluded to, viz., the 
increased depth of the uterine cavity. The history of the case will 
generally enable us to decide, whether the tumor under examination 
is one caused by inflammation or not; the inflammatory tumor, more- 
over, is seldom movable. A hematocele is behind the uterus, is 



PEOGNOSIS. 619 

elastic, and has the shape of the cul-de-sac, instead of being glob- 
ular. 

When the tumor is large enough to fill up the abdominal cavity, 
and become immovable in consequence of its bulk, it is usually but 
not always elastic. If so, it has become fibro-cystic. We cannot 
always determine the relation of these tumors to the uterus by the 
methods I have described. Often we are unable to introduce a sound 
into the uterine cavhy, in consequence of its tortuous direction, and 
the diagnosis becomes extremely difficult. These are the tumors, as 
I have before said, that have been mistaken for and removed as 
ovarian tumors. Probably the only positive way of clearing up the 
diagnosis, is to draw off some of the fluid with a trocar, or aspirator, 
and make its character the test. Dr. Washington L. Atlee, of Phila- 
delphia, in his admirable work on the Diagnosis of Ovarian Tumors, 
has furnished us with a description of the fluid derived from this 
kind of fibrous tumor, that is every way correct. The fluid does not 
run out of the canula of the trocar with the facility with which the 
ovarian fluid is evacuated, and often when it is received in a vessel, 
and becomes somewhat cool, it coagulates, and like blood separates 
into clot and serum. When examined by the microscope, debris of 
blood-corpuscles and fibrillar of fibrin are the characteristic substances 
found. One other circumstance I have failed to call attention to is, 
that fluctuation observed upon percussion is less decided than in 
ovarian tumors. If the tumor is large enough to distend the abdo- 
men, it may be complicated with peritoneal dropsy. This condition 
also renders the diagnosis obscure. Tapping will generally enable us 
to arrive at correct conclusions. After the ascitic fluid has been re- 
moved, an examination of the tumor will enable us to establish its 
relations to the uterus, as well as determine its density and shape. 

The fluid in these cases should be submitted to microscopic exam- 
ination with a view to ascertain whether it came from an ovarian cyst 
or the peritoneal cavity. 

Prognosis. 

There are several considerations which render the general prog- 
nosis favorable as compared with other tumors for which they may 
be mistaken. 

They occur generally in persons who have made a near approach 
to the menopause, and generally they cease growing after this condi- 
tion is passed. They grow slowly, and may not be expected to arrive 
at dimensions sufficiently great to cause fatal consequences for many 
years, if ever. They often stop growing without any discoverable 
reason ; they sometimes undergo degeneration into inert masses, 
which remain as mere inconvenient bodies. Nature sometimes gets 
rid of them by expulsion, or they may be protruded from the uterus 



620 TUMORS OF THE UTERUS. 

into the vagina, within reach of surgical measures. Lastly, many of 
them disappear under judicious medical treatment, or all the threat- 
ening symptoms attendant upon them may be removed by such 
means. 

Almost none of these conditions obtain in ovarian tumors and very 
few in any others found in the same locality. These considerations" 
will establish the conclusion that the general prognosis is favorable. 

The circumstances which in individual cases form an unfavorable 
prognosis are : the youth of the patient, as they usually grow more 
rapidly in young persons; the rapid growth of the tumor; hemor- 
rhagic symptoms; unfavorable complications, as peritoneal dropsy, 
inflammation in the pelvis or abdomen, pressure upon the pelvic 
organs, nerves, or vessels ; inflammation of the tumor, impaction in 
the pelvis, uraemia, anaemia, pregnancy, ovarian tumor, etc. The 
fibro-cystic variety possesses several elements of danger ; its rapidity 
of growth being the cause of several others, as pressure, impaction, 
dropsy, etc. 

The complications of pregnancy and labor with fibrous tumors of 
the uterus is one of sufficient importance to demand special consid- 
eration, especially as we may be obliged to determine a course of 
action when the emergency leaves no time for research. The simple 
coexistence of a fibrous tumor with pregnancy is not sufficient reason 
for interference, and I am persuaded from personal observation that 
there are but few cases which call for any interference whatever. 

I do not wish to be dogmatic, but I desire to make a few definite 
statements of what I regard as facts. Pregnancy takes place more 
frequently when the tumor is situated in the central zone of the 
uterus and remote from the mucous membrane ; but it will not occur 
if the tumor belongs to the submucous variety, although it is in the 
middle, or even in any part of the uterus except the cervical portion 
of the inferior zone. I have already intimated that there are very 
few large tumors developed in the inferior or cervical zone compared 
with those that arise from the central corporeal and superior or fundal 
zone, and that such as these are usually developed in the submucous 
tissue and are generally pendulous — these do not appear to interfere 
very much with pregnancy. From what I can learn and have ob- 
served pregnancy seldom, if ever, takes place when the tumor, being 
of more than moderate size or situated near the mucous membrane, 
is located in the fundus or upper portion of the superior zone. In 
general the larger the tumor the less likelihood of pregnancy, and if 
it does occur the impossibility of normal uterine development leads 
to abortion. 

The clangers to be apprehended arise usually at the time of labor 
and consist: 1, In the obstruction to delivery caused by the tumor 
blocking up the pelvis ; 2, in the incomplete contraction after delivery 



PROGNOSIS. 621 

failing to close up the placental vessels, and thus causing grave, if not 
fatal, hemorrhage. Tumors situated in the superior zone, the middle 
zone, or the upper portion of the inferior zone will offer little obstruc- 
tion, because the head will have passed them above the pelvic brim. 
This leaves but a limited number and those small in size that are 
crowded down into the pelvis by the side of or before the fetal head ; 
they are the submucous or polypoid variety situated in the cervical 
portion of the inferior zone. Such tumors are generally pressed en- 
tirely out of the vulva and permit the head to pass out after them. I 
may mention, in passing, that they may sometimes be detached from 
their base by the pressure of the head ; or, remaining intact, may be 
retracted within the pelvis after the labor is over. 

The second danger is, I think, very much overrated. The fact of the 
fibrous tissue of the uterus having been developed sufficiently to per- 
mit of the completion of gestation is an evidence that it is sufficiently 
powerful to contract fully, and one single case recently published by 
Dr. Chadwick, of Boston, in which the placenta was implanted on the 
uterus over the seat of the tumor, and in which hemorrhage did not 
prove serious after delivery, goes far to prove that great danger from 
this cause is not likely to occur. In no case of labor associated with 
a tumor which has come under my own observation has hemorrhage 
been a grave symptom. 

It is fair, I think, in the light of our present knowledge, to infer that 
it is seldom necessary to interrupt pregnancy when complicated with 
fibrous tumors of the uterus, as, in the nature of things, gestation will 
not continue unless there is sufficient integrity of uterine tissue to per- 
mit ample development. At the time of labor the indication for 
operative procedure will appear in the want of progress, and then the 
obstacles may be surmounted by turning, or forceps, if the propulsive 
powers of the uterus are not sufficient. Common prudence will incite 
to vigilance in preventing hemorrhage in these as mother complicated 
cases of labor. It will be observed that while I cannot ignore the im- 
portance of watching these cases attentively, I am far from consider- 
ing them as necessarily very dangerous. 

Another question of great importance is, what effect does pregnancy 
and labor have upon the tumor? 

In a minority of cases none whatever. The tumor remains the same 
after the pregnancy has terminated as before. But in the majority of 
cases it is far otherwise. In three instances of this nature, which have 
come under my own observation, the tumors have disappeared ; and 
the manner of their disappearance is worthy of remark. In one in- 
stance, occurring two years since, the tumor was located in the posterior 
wall of the uterus, apparently in the central portion of it, and occupied 
the middle zone. The pregnancy proceeded without accident, and the 



622 tumobs of the uterus. 

patient was delivered at term of a dead foetus, which, judging from 
appearance, must have been dead three days before labor came on. 
Moreover, according to the calculation of the mother, the first pains 
did not appear until two weeks after the expiration of two hundred 
and eighty days. The head was arrested at the superior strait and 
impinged upon the symphysis pubis, but was easily moved from this 
position. I did not see the patient until four hours after the membranes 
had been ruptured. At this time the presenting part did not advance, 
and. after consultation with the attending physician. Dr. John F. AVil- 
liams. of this city, it was considered best to interfere. I introduced, 
my hand, seized one of the feet and brought it down. There was no 
great difficulty in the turning or delivery. The placenta came away 
in a few minutes with a very slight loss of blood. I had first seen 
this patient when gestation had advanced to the end of the third 
month. At this time I believed the tumor to be about the size of a 
fetal head at term. It was extremely hard, and presented two distinct 
nodules. At this consultation I advised non-interference. I saw her 
again several times during her pregnancy. She was a primipara. 
After the delivery of the placenta I felt curious to know what effect 
the pregnancy had upon the size and consistency of the tumor. In 
order to determine these points I introduced one hand into the uterus, 
and with the other manipulated above the symphysis. In this way I 
could fix and handle the tumor with facility. It then seemed to be 
about the size of the fetal head and very hard. The division between 
the firmly contracted uterus and the tumor was marked by a well-de- 
fined sulcus, traceable by the hand, above the pelvic brim. The 
tumor seemed harder than the contracted uterus. I had the oppor- 
tunity of seeing and examining this patient frequently during the 
year succeeding her accouchement. The tumor was decidedly less 
in three months, and continued to disappear. At the expiration of 
twelve months it was no longer perceptible, and the cavity of the uterus 
measured but two inches and a quarter. The patient now menstruates 
normally in every respect. 

The careful observation of this case convinced me that the tumor 
had net grown materially larger nor become softened during gesta- 
tion, and led me to believe that the process of absorption began and 
proceeded with the subsequent involution of the uterus. What effects 
may have been wrought upon its tissues by the contractions during 
labor I cannot, of course, determine : but the gradual disappearance of 
the tumor and the non-appearance of inflammatory or other urgent 
symptoms plainly indicate that the contractions of the uterus during 
labor could not have produced any very violent effects upon it. It 
was also evident that the tumor was absorbed and slowly removed 
without disturbing the good health of the patient. 



prognosis. 623 

In the other two cases I verified the existence of fibrous tumors 
before pregnancy took place, and one of them I saw again after a lapse 
of five months, but was not present at the time of parturition of either 
of them, nor have I seen them subsequently. I have been assured, 
however, by letters from their attending physicians, that they recog- 
nized the tumor after labor, and that they both disappeared within a 
year. 



CHAPTEE XXXIX. 

FIBEOUS TUMOKS OF THE UTEEUS {Continued). 

Treatment. 

The treatment of fibrous tumors of the uterus consists largely of 
the means calculated to relieve such symptoms as endanger the life 
of the patient or materially affect her general health. When these 
are unavailing, resort is had to measures calculated to get rid of the 
tumor. Some remedies necessary to the relief of symptoms act as 
very powerful curative agents ; hence, while it is convenient to speak 
of the treatment of symptoms under one division of the subject, and 
the methods employed for radical cure under another, we cannot, in 
fact, completely separate these two branches. The reader will not be 
surprised, therefore, if I feel myself obliged to depart from this arbi- 
trary method of presenting my subject. 

Hemorrhage is by far the most important of the symptoms con- 
nected with these growths, because it is at the same time the most 
frequent and hazardous. It is also the symptom that leads to most 
suffering in consequence of depriving important organs of the blood 
necessary to support them in their functions. Every means, there- 
fore, should be made use of not only to prevent fatal losses but also 
to prevent even slight hemorrhage. In the outset, therefore, I would 
insist upon watching with great vigilance to prevent any unusual loss 
of blood. It will be understood by this that I advise not to tem- 
porize by adopting the milder and less efficient measures as being 
sufficient for cases not likely to prove fatal, but to treat all hemor- 
rhage arising from this cause with promptitude and energy. Fortu- 
nately in many cases we can anticipate the attacks of hemorrhage 
because we know when they will recur, and we are generally able 
to judge of their probable severity. To discharge our duty in this 
respect effectually, our patient should be properly provided with 
remedies and fully instructed how to use them. She should be made 
to understand that unusual hemorrhage at the menstrual period may 
be checked without endangering her general health. Among the 
remedies are dorsal recumbency with the hips elevated, cold to the 
hypogastric region, and cold to the dorsal spine and sacrum, which 
can be effected by means of a rubber pillow filled with ice water, 
ergot and some form of tampon. The best fluid extract of ergot in 
drachm doses, if the stomach will bear it, is probably the most effica- 
cious medicine, but the fresh drug in the form of infusion is also very 



TREATMENT. 625 

efficient. Full doses should be given every half hour when there is 
much loss, until some effect is produced upon the hemorrhage, and 
then continued every four hours as long as necessary. Compressed 
sponges saturated with the solution of alum make the best tampon 
for the patient to make use of. These may be made and kept in 
readiness, so that they can be introduced as soon as they are found 
necessary. The patient or nurse can make them by taking a fine 
sponge, large enough to fill the vagina, passing a piece of strong string 
through the centre to aid in its removal, and then, after dipping it in 
the solution, well winding it with twine from one end to the other, 
compressing it into as small a space as possible. The twine should 
so compress the sponge as to make it assume an elongated form. It 
should then be laid aside and permitted to dry. Several sponges 
should be thus prepared and dried. When necessary the twine may 
be unwound and the sponge introduced. Its size when in the dry 
condition will allow of an easy passage into the vagina, where the 
moisture will cause it to expand, thus filling up and sealing the 
vagina so as to absolutely check the discharges. If the attending 
physician is present he may tampon the vagina with pellets of cotton 
secured by thread and moistened with the solution of iron, as recom- 
mended by J. Marion Sims and others. The inconvenience experienced 
from this ironized plug will be more than counterbalanced by the 
saving of blood. This form of tampon has the additional advantage 
of being antiseptic. I have allowed it to remain for three days, and 
upon removing it satisfied myself that there was no decomposition of 
the blood or the vaginal secretions. When the tampon is removed it 
will not be found difficult to wash out all the granular clots caused 
by its presence. It may be repeated as often as necessary, but usually 
if allowed to remain forty-eight hours the hemorrhage will not return. 
It may be said that for small losses this is unnecessary, but I think 
this is a more convenient form of tampon than any other that will 
answer the purpose. In dangerous cases no one will question the 
propriety of its employment. 

Another very important means of arresting hemorrhage, which can 
be used by the physician when necessary, is the introduction of a 
compressed sponge into the cervix uteri for the purpose of dilating it. 
This will temporarily act as a tampon and stimulate the uterine fibres 
to contraction. A point of much importance in the use of the tampon 
or sponge, is the avoidance of septicemic poison, and I know no 
medicine so efficacious and handy as the preparation of iron I have 
mentioned. 

The pressure of the tumor upon the pelvic viscera is another in- 
convenience which calls for attention. This takes place usually at a 
time when the tumor has acquired a size sufficient to fill that cavity. 
Consequently the elevation of the tumor above the pelvis is the 

40 



626 FIBROUS TUMORS OF THE UTERUS. 

remedy. This may be done sometimes by placing the patient in the 
knee-elbow position and opening the vagina by two fingers, and then 
pressing the growth upwards. The powerful influence of atmos- 
pheric pressure called to our aid, by the position and opening of the 
vagina, is a very material auxiliary in the process of elevation. If this 
is not sufficient, we may pass the fingers into the rectum and elevate 
the tumor. I once succeeded in this operation by using an ivory- 
headed cane in the rectum when the fingers failed to reach high 
enough. 

D} T smenorrhcea is another symptom of fibrous tumors, and some- 
times a ver}^ distressing one, which we are often called upon to re- 
lieve. It depends, no doubt, as I have before said, on the imprison- 
ment of blood in the uterine cavity, in consequence of the tortuosity 
of the canal causing the closure of some part of it. The remedy con- 
sists in dilating these narrow places. I know of nothing so well cal- 
culated to effect this object as the slippery elm tent. A tent of this 
material, long enough to reach the fundus uteri, and of sufficient size, 
moistened so as to render it very flexible, may be passed up through 
these tortuous places with great facility. If introduced as soon as 
the symptom begins to manifest itself, and allowed to remain an hour 
or two, the relief will be pretty certain. If used once a day, for four 
or five days before the attack, and three or four hours at a time, dys- 
menorrhcea may be generally avoided. 

When we broach the question of the permanent cure of these affec- 
tions, we find that great difference of opinion exists among the mem- 
bers of the profession as to the value of medicines. One part, per- 
haps a majority, believe that no medicine has any direct effect upon 
them, and they ignore any means of permanent relief but surgical. 
There is, however, a respectable number of medical men who place 
great reliance upon the administration of certain medicines, and, if I 
am not mistaken, recent observation has added greatly to their num- 
ber. The^y do not, however, wholly agree as to the therapeutic pro- 
cesses that should be instituted, and consequently do not employ the 
same kind of medicines. Some gentlemen have more confidence in 
what I will term the sorbefacient process of treatment. They endeavor 
to institute measures that will cause the absorbents to attack and 
remove the neoplasm in the same way that tumefactions caused by 
effusions are removed. This they clo by friction, pressure, and the 
administration of the old-fashioned sorbefacient medicines. The most 
popular among these are the iodides, chlorides, and bromides of mer- 
cury, potassium, sodium, calcium, and ammonium. Reports may be 
found in books and our periodical medical literature of cures by sev- 
eral, if not all, of these articles and their combinations. The late Dr. 
W. L. Atlee, whose experience has been very extensive, had great con- 
fidence in the action of chloride of ammonium. He caused it to be 



TREATMENT. 627 

administered internally, applied externally, and used as vaginal injec- 
tions. The iodide of potassium has long enjoyed a great reputation 
in causing the absorption of these and other forms of tumors. There 
is no professional fairness in assuming that the faith in these remedies, 
derived from the observation of their effects, or the promulgation of 
cures from the use of sorbefacient measures, are fallacious. Some of 
the men arrayed in favor of the opinion that cures may be effected by 
a patient and long-continued administration of some one of the arti- 
cles I have mentioned, stand high as men of honesty, accuracy of 
observation, and faithfulness in their records ; and for one I give full 
credence to their statements. Yet I must also say that I have not 
witnessed the good results which I unhesitatingly believe others have 
seen from the sorbefacient treatment alone. 

Others who expect much from medicinal treatment look to that 
class of medicines which causes contraction of the unstriped muscular 
fibres as the most promising. With these medicines they expect to 
diminish the supply of blood to the tumor, by causing contraction of 
the arterioles traversing their substance, and thus disturbing their nu- 
trition to such a degree as to stop their growth, lessen or destroy their 
vitality, and so render them subject to the influence of the absorbents, 
whereby they may be removed. Some of the more energetic of these 
medicines, as ergot, for instance, often affect these growths very 
promptly. 

I shall limit my remarks upon this class of medicines to what is 
known of the effects of ergot. 

As an introduction to what I have to say of ergot I submit the fol- 
lowing propositions : 1. When property administered, ergot frequently 
very greatly ameliorates some of the troublesome and even dangerous 
symptoms of fibrous tumors of the uterus, e. g., hemorrhage and co- 
pious leucorrhcea. 2. It often arrests their growth and checks hemor- 
rhage. 3. In many instances it causes the absorption of the tumor, 
occasionally without giving the patient any inconvenience; at other 
times the removal of the tumor by absorption is attended by painful 
contractions and tenderness of the uterus. 4. By inducing uterine 
contraction it causes the expulsion of the polypoid variety. 5. In the 
same way it causes the disruption and discharge of the submucous 
tumor. 

There are many cases on record to substantiate every one of these 
propositions. 

From what I consider well-authenticated sources, including the 
cases under my own observation and in the practice of my friends 
and neighbors, I have collected one hundred and thirty-six cases of 
fibroid tumors treated by ergot. Of these, twenty-five cases were 
cured without giving the patient any inconvenience from painful con- 
tractions. In forty-six cases the tumors were diminished in size and 



628 FIBROUS TUMORS OF THE UTERUS. 

the hemorrhage was cured. In twenty-seven others the hemorrhagic 
symptoms were relieved, while the size of the tumor was not affected. 
In eight other instances the tumors were broken to pieces and expelled 
piecemeal. 

At the risk of being tedious I will copy the summary of cases and 
opinions reported to me and given in my address on Obstetrics made 
before the American Medical Association in 1875 : 

Cases. 

It is well known that Professor Hildebrandt, in a communication 
to the twenty-fifth number of the Berliner Wochenschrift, as early as 
1871, called the attention of the profession to the utility of ergotin in 
the treatment of fibrous tumors of the uterus. While administering 
it by hypodermic injections to moderate the hemorrhages, so often a 
troublesome symptom in connection with these growths, he was struck 
with the decided diminution in the size of the tumor. A continuation 
of the remedy thus administered resulted in the entire disappearance 
of one of them in fifteen weeks. In eight cases, all but two under- 
went great improvement. The great pain caused by injection ren- 
dered the treatment intolerable to one of these two patients. In the 
other the treatment was discontinued on account of ergotic intoxica- 
tion. In four others, the tumors were greatly diminished, and promised 
speedy cures, but for various reasons the treatment was not continued. 
One tumor of huge size, reaching above the umbilicus, totally disap- 
peared ; while another, extending to the ribs, and largely distending 
the abdomen, was greatly reduced. The debilitating hemorrhages 
and leucorrhceal discharges were promptly relieved in six of them. 

In the American Journal of Obstetrics for January, 1875, Dr. Hilde- 
brandt gives a synopsis of nineteen more cases treated by him. Two 
of these were cured ; and in six others the tumors were greatly dimin- 
ished in size, and the hemorrhages relieved. In eleven of these cases 
all the disagreeable symptoms were relieved, but the size of the tumor 
was not perceptibly affected. The last two cases reported in this 
series of nineteen were not benefited. 

Soon after Professor Hildebrandt made his first report of cases, Dr. 
Bengelsdorf read a paper upon the subject at a meeting of the Griefs- 
wald Medical Society. He alluded to four cases in which he had 
used the hypodermic injections of ergot. Two of these were in pa- 
tients after the menopause ; neither of them seemed to be influenced 
by the treatment. In the other two the patients were menstruating 
and the subjects of severe metrorrhagia. This symptom in both cases 
was very much mitigated, but the tumors were not materially, if at 
all diminished in size. Treatment was interrupted in one of them 
after the administration of sixteen injections. Dr. Bengelsdorf was 
favorably impressed by the treatment. 



cases. 629 

Dr. Chrobak, of Vienna, reports, in the seventh volume, second 
number, of the Archives jur Gynacologie, nine cases. In the first, the 
tumor the size of a small apple was partially expelled from the cavity 
of the body into the cervical canal; the mouth of the uterus was 
dilated by sponge, and the protruding segment removed with the 
scissors. In case second, after forty -three injections, the tumor, 
which was situated in the posterior wall of the uterus, was not re- 
duced in size, but the hemorrhage was cured. The tumor in case 
third consisted of several nodules in the anterior wall of the uterus ; 
after twenty-four injections, there was no diminution in size, but the 
hemorrhage was cured. In case fourth the tumor was situated in 
the posterior wall and reached up to the umbilicus ; after three in- 
jections the treatment was discontinued on account of the pain and 
inflammation caused by them. In the fifth case the amount of hem- 
orrhage was reduced, but the treatment was discontinued for the same 
reason as in case fourth. The tumor in case sixth was large, the 
uterus rising above the umbilicus; after twelve injections without 
results, the patient could not be induced to receive further treatment. 
The seventh patient was fifty-seven years old, and the tumor showed 
a multitudinous development; the second injection, which was ad- 
ministered eight days after the first, caused severe symptoms of 
collapse, and the treatment was discontinued. The tumor in the 
eighth case was in the anterior wall of the uterus and reached above 
the umbilicus, and the monthly flow continued from eight to ten 
days ; seven injections were used, with diminution of the tumor and 
improvement in the hemorrhages; the treatment in this case he ex- 
pected to continue at some future time. In the ninth case the uterus 
was anteverted, and the cavity measured four and three-fourths inches 
in length ; after twelve injections the hemorrhages ceased and the 
tumor diminished in size ; the uterine cavity measuring only three 
and one-third inches in length. 

Dr. Lombe Atthill records three cases in the Irish Hospital Gazette 
for September 1st, 1874. The first case was benefited in the diminu- 
tion of the flow and the improvement of health. The second case 
was under treatment but a very short time ; only five injections were 
administered, when the patient refused to permit another because of 
the severe inflammation following them. The third case was bene- 
fited, but abandoned from the same cause. 

Dr. J. P. White, of Buffalo, N. Y., writes me that he believes it is 
in this direction — the use of ergot — we must look for relief in the 
intramural and non-pediculated varieties of uterine fibroids. He says 
that in the last year and a half he has resorted to ergot in these vari- 
eties with marked benefit. In a few instances they have been com- 
pletely absorbed, and in a larger number the growth of them was 
arrested, the tumors were diminished in size, and the hemorrhages were 



630 FIBROUS TUMORS OF THE UTERUS. 

suspended. He says that the number of his cases is fourteen, and 
that not more than one-third can be called cured, while in almost the 
same proportion, the growth has been stayed or diminished, and the 
bleeding arrested. 

Dr. E. W. Jenks, of Detroit, Michigan, now of Chicago, in a recent 
letter, says, he has used ergot during the past two years in the treat- 
ment of fibroid tumors of the uterus with the most gratifying results. 
Seventy-five per cent, of all cases thus treated were benefited, as 
manifested by arrest of growth and control of hemorrhage. About 
ten per cent, of the patients he considered cured. 

Dr. H. C. Howard, of Champaign, 111., sends me an account of two 
cases treated by him. The first case was in an unmarried woman. 
The tumor was one originating from a single nucleus, intramural, 
and as large as a pint measure. He administered hypodermic injec- 
tions of ergotin for some weeks, and afterward continued treatment 
for eight months by administering internally the fluid extract of ergot 
and belladonna. This case, he says, was entirely cured by his treat- 
ment. His second case was in the person of a married woman, forty 
years of age, and the mother of two children. When first seen by 
him she had been the subject of severe floodings for three years. He 
found, upon examination, a submucous fibroid as large as a quart 
cup. He used large quantities of ergot by vaginal injections and by 
the mouth for four months, at which time the tumor had entirely 
disappeared. 

Dr. A. Reeves Jackson reported to the Chicago Society of Physi- 
cians and Surgeons, April 13th, 1874, five cases of fibrous tumors of 
the uterus treated by hypodermic injections of the solution of the 
solid extract of ergot. The tumors in four of these cases were intra- 
mural; in the fifth the tumor was subperitoneal. The tumor in one 
was entirely cured ; in two others the tumors were greatly diminished 
in size. In another the tumor seemed unaffected, but the profuse 
hemorrhages from which the patient suffered were diminished in fre- 
quency and profuseness. The fifth, a subperitoneal tumor, was not 
benefited. 

Dr. Jackson reports to me three other cases. One was in a colored 
woman ; the uterus reached to the umbilicus ; it was entirely cured 
in three months. In the second the tumor reached above the umbili- 
cus; this was temporarily reduced in size by the ergot, but after 
treatment was abandoned, it regained its former dimensions. The 
treatment was discontinued by the patient because of the distressing 
pain and contractions which occurred after eight weeks' use. The 
profuse uterine hemorrhage was checked, and health improved. 

At the same meeting of the Society of Physicians and Surgeons at 
which Dr. Jackson's first five cases were reported, Dr. Etheridge 
reported one case entirely cured. His diagnosis was confirmed by 



CASES. 631 

Drs. Gunn and Miller, Dr. Etheridge's associate professors in Rush 
Medical College. Dr. Fisher also reported an intramural fibrous 
tumor cured in six weeks. I saw this case, and have no doubt of 
the correctness of Dr. Fisher's diagnosis. 

On the same occasion Dr. Merriman, one of my colleagues, re- 
ported three cases ; one, intramural, in the anterior wall, cured ; one, 
subperitoneal, pediculated ; the health of this patient was much im- 
proved, and the growth of the tumor checked ; the patient was still 
under treatment. The tumor in the third was intramural. At the 
time of reporting, the size was gradually diminishing. 

Dr. John Morris, of Baltimore, Md., communicates to me a case 
that seemed to be decidedly benefited by the ergot treatment ; but, 
on account of the violent uterine contractions produced by the remedy, 
the patient would not consent to continue the treatment. 

Dr. Charles E. Buckingham, of Boston, Mass., has tried hypodermic 
injections of ergot in the treatment of fibrous tumors of the uterus in 
but one case. The result was entirely negative. 

Dr. George Cowan, of Danville, Ky., reports a case in the person of 
a colored woman, unmarried, and about forty years of age. The hypo- 
dermic injections of ergotin were used for two weeks. At the end of 
this time the greatest circumference of the abdomen was reduced from 
thirty-six inches, which it measured before the treatment was insti- 
tuted, to twenty-eight and one-half inches. The patient, returning 
home, used the injections herself. Such frequent and painful abscesses 
ensued, however, that she discontinued them. During the use of the 
injections an obstinate constipation was removed, and her general 
health much improved. The abandonment of the treatment was fol- 
lowed by a return of the constipation, loss of flesh, great debility, and 
the abdomen increased in size until it measured thirty-two inches. 
A return to the treatment was followed by the same marked improve- 
ment in the general health, and a reduction of the size of the abdomen 
to twenty-seven and one-fourth inches. 

Dr. H. W. Dean, of Rochester, N. Y., sends me an account of two 
cases treated by him. The first case was that of a patient forty-seven 
years of age, the mother of three children, the age of the youngest 
nineteen. She suffered from pressure upon the bladder and rectum, 
and was the subject of severe menorrhagia. The tumor extended two 
inches above the umbilicus, and occupied the lower half of the right 
lumbar, the whole of the right inguinal, and fully half of the corres- 
ponding left abdominal regions. The os uteri was a little to the left 
of its natural position, and sufficiently open to admit the finger half 
an inch. An elastic catheter was introduced into the uterine cavity 
between seven and a half and seven and three-fourths inches. The 
diagnosis was interstitial fibrous tumor of the uterus. Intrauterine 
injections, through the elastic catheter, of half a drachm of Squibb 's 



632 FIBROUS TUMORS OF THE UTERUS. 

fluid extract of ergot were made four times during each menstrual in- 
terval, from April until October, 1874. Injections into the substance 
of the cervix were made with the same frequency from October to the 
middle of December. The results were, reduction in the size of the 
tumor until the upper margin sank two inches below the umbilicus, 
and the uterine cavity measured only four and a half inches. 

The second case was that of a woman, forty-eight years of age, the 
mother of three children, the youngest of whom was sixteen. She 
flowed irregularly, the intervals varying from one to three weeks. The 
flow was profuse and attended with great pain. In the intervals there 
was a copious flow of serous leucorrhcea. She also suffered from 
pressure upon the bladder and frequent micturition. The tumor oc- 
cupied the right side of the abdomen, extending nearly to the umbili- 
cus, and to midway between the linea alba and the left ilium. The 
vagina could not be satisfactorily explored until the hand was intro- 
duced. When this was effected the finger could be easily passed into 
the uterus. Between the finger thus introduced and the hand on the 
hypogastric region, the presence of an interstitial fibrous tumor was 
diagnosticated. A flexible catheter was passed into the uterine cavity 
to the extent of eight inches. Injection into the substance of the 
cervix was followed in fifteen minutes by continuous uterine contrac- 
tions, which lasted twenty -four hours. This injection was repeated 
four times a month. When the amount was increased from fifteen to 
twenty minims, great gastric and cerebral disturbance, together with 
intense cutaneous engorgement and uterine pain, ensued. The injec- 
tions were continued from November, 1873, to the middle of the year 
1874. At this time the upper margin of the tumor was but one inch 
above the symphysis pubis, and the cavity of the uterus measured 
four and a half inches. Menstruation was quite normal as to time 
and quantity, and attended with little pain. The pelvic organs were 
not subject to disagreeable pressure. 

Dr. W. C. Wey, of Elmira, N. Y., in a lengthy and interesting letter 
gives me the results of his treatment in one case. The patient was 
forty-seven years old. The bulk of the tumor was equal to both closed 
hands. It was reduced in six weeks about one-third, and in six months 
to one-half of its original size. The patient, before the treatment, was 
very much reduced ; her extremities had become cedematous, and ex- 
ercise was impossible from the effects of hemorrhage, which had 
become almost constant. These symptoms were relieved w T ith great 
promptitude and in four months the menses had become normal in 
every respect. His treatment was continued twenty-seven months, 
but most of the good results, if not all, were obtained in the first six 
months. 

Dr. Edward M. Hodder, of Toronto, writes me that the number of 
cases in his notebook, since May, 1873, is twenty-five ; but all of these 



cases. 633 

reside at a distance, and therefore he saw or heard of them only oc- 
casionally. Nearly the whole of them were treated with ergot, but 
not exclusively, as he combined with it the bromide and iodide of 
potassium. In the majority of the cases, treatment appeared to arrest 
further growth, and after a time caused the tumors to diminish in 
size. In a few cases the tumors disappeared entirely. He gives four 
cases in minutia? : in one case the treatment was commenced May, 
1873; the tumor nearly disappeared, and the patient is now six or 
seven months advanced in pregnancy. In the second case, the treat- 
ment was begun in June, 1873 ; the tumor was greatly diminished 
in size, the patient became pregnant, and was delivered late last 
autumn. In the third case the treatment was commenced in Sep- 
tember, 1873 ; the tumor disappeared, and the patient is now preg- 
nant. In the fourth case treatment was commenced in September, 
1873, and the tumor is now nearly gone, and the patient feels quite 
well. 

Through the kindness of Dr. Hodder I have received the report of 
another case by Dr. Jukes, of St. Catherines. The tumor was discov- 
ered by Dr. Jukes at the time of delivery after a normal pregnancy. 
The history of the case shows that its existence had been recognized 
by Dr. Hodder before the patient was married. Dr. Jukes gave the 
fluid extract of ergot continuously to this patient for three months, 
first in doses of one-half drachm, and afterwards increased the dose 
to one drachm, combined with the various preparations of iodine. 
From the beginning, the tumor slowly decreased in size, and at the 
end of three months had entirely disappeared. Some weeks after de- 
livery, he passed the sound into the uterine cavity six inches, and the 
organ reached very nearly to the umbilicus. After the three months' 
treatment the measurement by the sound showed the organ to be very 
slightly above its normal size. 

Dr. Strange, of Aurora, Canada, says that he had on several occa- 
sions given ergot internally to arrest the hemorrhage attendant upon 
fibrous growths in the uterus, and had observed that it tended to re- 
tard their further growth. 

Dr. L. F. Warner, of Boston, has used ergot in two cases of fibrous 
tumors of the uterus, but could perceive no beneficial effects. 

Dr. J. H. Thompson, Surgeon in Chief of the Columbia Hospital 
for Women and Children, reports three cases treated by ergot, in all of 
which the tumors were reduced in size, the metrorrhagia cured, and 
the general health, which in all was much impaired, was entirely re- 
stored. In one of these cases Dr. Thompson injected the ergot into 
the substance of the tumor by passing this instrument through the 
cervical cavity, and thence penetrating the growth. No unpleasant 
effects followed this method of using the remedy. 

Dr. Russel, of Oshkosh, Wisconsin, reports one case in which the 



634 FIBROUS TUMORS OF THE UTERUS. 

tumor, of large size, was very much reduced, and all the disagreeable 
symptoms were removed. 

During the year since the last meeting of the Association I have 
treated seven cases. 

One was not affected by the ergot, and the patient died six weeks 
after the commencement of the treatment. She was ansemic to a de- 
gree which I have seldom before seen. The remedy was administered 
hypodermically every day, thirty drops of Squibb's solution of the 
solid extract being injected each time. 

The second patient was the subject of a uninuclear tumor, situated 
in the anterior wall of the uterus, about the size of the fetal head. She 
had profuse hemorrhages at her menstrual periods, and copious leu- 
corrhceal discharges between them, and had become very anaemic. 
The discharge ceased and the tumor disappeared in five months from 
the time she first came under my care. The remedy was at first used 
hypodermically ; but, on account of the pain and inflammation at the 
punctures, I was obliged to cease this mode of administering it, and 
gave it internally. Teaspoonful doses of Squibb's fluid extract were 
given twice a day for the last three months of the time the patient was 
under treatment. 

In three other cases, in which the medicine was given internally, 
the tumors were very much reduced in size, but did not disappear. 
The hemorrhages and leucorrhoea were cured, and the patients restored 
to health. 

In another, the hemorrhages and leucorrhoea were rendered much 
less profuse, but the tumor was not reduced in size. 

In a colored senile patient, over sixty years of age, with a large 
multiple tumor, no effect was produced by the ergot. 

In four of my cases I was obliged to suspend the treatment several 
times for a few days, to give the patients a respite from the almost 
constant pain. 

Five of these complained of great heat and tenderness of the uterus 
after they had been under treatment about four weeks. 

In all, the pulse was accelerated and remained small and weak. 

As one of my cases presented some features of more than ordinary 
interest, I. will give it more in detail : The patient had been married 
twelve years, was thirty-seven years old, and sterile. She had been 
aware of the existence of the tumor for three years, but could not 
give a very clear history of its progressive enlargement. The uterus 
extended three inches above the pubes, and was a little to the right of 
the median line, very hard, and irregular in shape ; but I could not 
discover that there were subperitoneal nodules. Per vaginam, the 
tumor could be felt to occupy the right side and anterior wall of the 
uterus, and fill up two-thirds of the pelvic cavity. The cavity of the 
uterus measured four and a quarter inches. A polypus, pyriform in 



cases. 635 

shape, quite firm in consistence, about the size of a pigeon's egg, de- 
pended from the mouth of the uterus, and appeared to be attached 
to the upper part of the posterior wall of the cervix. The diagnosis 
was intramural fibrous tumor of the uterus, with two nuclei of devel- 
opment, and a fibrous polypus. The patient was somewhat anaemic 
from the long continuance of profuse leucorrhcea and metrorrhagia. 
Without removing the polypus, I commenced treatment by giving 
the patient three grains of the solid extract of ergot three times a day. 
The next menstrual flow was not so profuse, and the leucorrhcea di- 
minished almost from the beginning. At the end of four months the 
menstruation was normal, the leucorrhcea had ceased, the tumor was 
reduced to half its former dimensions, and the patient's health re- 
stored. A continuation of the treatment two months longer causing 
no further reduction of the tumor, it was suspended. During the 
treatment, I watched with much interest the effects produced upon the 
polypus, examining it once in every ten or twelve days. It showed 
decided decrease in size at the end of the first ten days, and progres- 
sively decreased until, at the expiration of four months, it was not 
more than one-third the size it presented when first examined. It was 
twisted off at this time with great ease, and its removal was followed 
by almost no loss of blood. 

The most remarkable case of which I have any knowledge was re- 
ported to me by Dr. G. C. Goodrich, of Minneapolis, in which absorp- 
tion of a large tumor took place under the administration of ergot and 
belladonna. I subjoin his description : 

"The treatment was commenced in 1870, and continued two years. The uterus 
filled the whole apace between the ilia, and measured in the transverse diameter 
twelve inches, and in the vertical nineteen inches, extended up under the ensiform 
cartilage and close up to the margin of the cartilages of the ribs. The treatment was 
followed by cramps in the uterus, which produced a wild enthusiasm in the mind of 
the patient, and inspired her with strong hopes of recovery. Without consulting me, 
she doubled the dose of medicine, which was administered internally, and as a conse- 
quence she was attacked with very strong uterine contractions and symptoms of me- 
tritis. This caused me to abandon treatment for about one month, and had it not been 
for the urgent determination of the patient, I would not have resumed it. She in- 
sisted that as this was the first medicine which had ever affected the enlarged organ, 
she believed it would cure her, and promised to obey my directions if I would pro- 
ceed. She so promptly and rapidly improved that I doubted if it were not a coinci- 
dence with, rather than a consequence of, the treatment. Prompted by this doubt, I 
abandoned the use of the ergot and belladonna and continued alterative treatment. 
The patient soon assured me that she no longer felt the griping pains caused by the 
remedy, and that the tumor was softer and larger than when she took the ergot pre- 
scription. The ergot and belladonna were again resumed, and in four months she 
was able to make a trip to Boston alone. While ahsent, she continued to take the 
medicine. From this time she continued rapidly convalescing, and is now in the en- 
joyment of fine health."* 

* The author's address before the American Medical Association at its meeting in 
1875. 



636 FIBROUS TUMORS OF THE UTERUS. 

I subjoin cases in which the tumors were expelled piecemeal under 
the administration of ergot, which came under my own observation : 

The first case in which this process was attained occurred in the 
practice of Dr. H. P. Merriman. So far as I am aware it is the first 
case on record. With several other medical gentlemen I had the 
opportunity of seeing the patient several times, fully verifying the 
diagnosis, and witnessing the results of the treatment. 

It was recorded in my address before the American Medical Asso- 
ciation already referred to. Dr. Merriman says : 

" Mrs. K., aged thirty, the mother of three children, came to me in September, 1S74, 
in regard to a tumor in the abdomen. Examination revealed a large tumor about the 
size of a four and a half months' pregnancy ; it was found to be interstitial, and situ- 
ated on the right side and a little anterior; the sound passed six and three-fourths 
inches. She was at once given twenty drops of fluid extract of ergot (Squibb's) three 
times a day. She came a month later saying she was much better in health, but the 
tumor remained the same. I told her to continue the medicine, but to increase the 
dose to twenty-five drops and after a time to thirty. I have seen her three or four 
times during the past winter, and twice had to suspend treatment and give opium on 
account of severe pain and tenderness in the uterine region. Finally, March 23d, 
1875, I stopped all use of ergot, as the patient was very weak, the pulse 110, the appe" 
tite poor, and a very offensive and abundant discharge was coming from the uterus. 
The os uteri was very patulous. On April 5th, I was summoned in great haste. Some- 
thing had just come away from the patient. I found it to be an offensive fleshy mass, 
evidently a disintegrated fibrous tumor. Examination showed no tumor in the abdo- 
men, but per vaginam the os patulous, soft, and very sensitive, and the uterus still 
large. A week latter the uterus had regained its normal condition." 

As an evidence of the complete restoration of the health of the pa- 
tient, Dr. Merriman informs me that she has since had a fine healthy 
child. 

The next case, which has never been published, occurred in ruy 
own practice, and I will give a brief account of it: Mrs. W., forty 
years of age, had been married eighteen years, and had not borne 
children or been pregnant. She had enjoyed good health and noticed 
nothing unusual in her menses until about three years before she con- 
sulted me on July 17th, 1875. Three years ago she began to have 
an increased menstrual flow, the intervals were shorter, and she be- 
came the subject of an acrid leucorrhceal discharge. For the last 
seven or eight months the flow has been almost constant, but moder- 
ate. The catamenial periods had been during the time well marked 
by a profuse discharge every four weeks. She was quite feeble from 
the great loss of blood she had sustained, very nervous and dispirited. 
For more than a year she had been conscious of the presence of a 
tumor in the hypogastric/region. She had at no time observed that 
the discharge was fetid, or indeed had any smell. By palpation, a 
tumor could be found extending to within about two inches of the 
umbilicus, and filling up the same space in the lower part of the ab- 



cases. 637 

domen which the uterus occupies at five months' pregnancy. It was 
globular, very hard, somewhat nodulated in shape, and movable. 
The cervix, when examined per vaginam, was ascertained to be long 
and pointed, and the mouth small, and not at all patulous. The 
probe entered the uterine cavity, passing upward and backward fully 
four inches, and moved with the impressions made upon the tumor 
above the symphysis. 

From the history and examination it was not difficult to diagnose 
a fibrous tumor in the anterior wall of the uterus. 

I prescribed thirty drops of the fluid extract of ergot three times a 
day, to be taken in a wineglassful of water, and large injections of 
cold water twice a day. 

On July 19th the patient called to see me again. She informed 
me that the medicine had caused great pain in the tumor, resembling 
cramps, with a strong desire to bear down, as though something was 
coming out of her. An examination revealed no change in the size 
of the tumor, but increased hardness and irregularity of its surface. 
She was directed to continue the medicine. On the 25th the patient 
complained that the pains were almost unendurable on account of 
their severity and continuousness. She said they prevented her from 
sleeping, or resting in any position. For the two days previous to 
her call on the 25th she had noticed in the discharges — which were 
less bloody — stringy and lumpy substances. This was different from 
anything she had seen before. Still there was no fetor. The tumor 
seemed to be somewhat less in size than upon the first examination. 
There were some changes in the cervix ; it was soft, and the mouth 
was patulous ; the finger entered it a short distance, but would not 
pass the inner os uteri. The cervix was still as long as before the 
commencement of the pains, and I thought the lower portion of the 
tumor seemed more elastic than at first. 

On the 27th the pain was so severe and persistent that I thought it 
advisable to diminish the doses of ergot, and directed her to take only 
fifteen drops three times a day. The discharge was increasing in 
quantity, and she gave me several pieces, one of which was as large as 
a cherry. It was so firm that it was difficult to break it up with the 
fingers, and of grayish color. There was no odor that I could dis- 
cover in the piece examined. 

Dr. W. H. Warn was kind enough to examine this specimen with 
the microscope. He found it composed mostly of hypertrophied con- 
nective-tissue fibres, with bloodvessels running parallel to them. The 
tumor had decidedly decreased in size. 

On July 31st the pains, with less severity, were still continuous for 
the greater part of the day and night. There was a constant discharge 
of these small fibrous lumps. Judging from a close examination, the 
tumor was not half so large as when first seen. 



638 FIBROUS TUMORS OF THE UTERUS. 

The discharge continued without diminution until the fifteenth of 
August, when it became less, and the pain also decreased. At this 
time the upper part of the tumor could barely be felt above the sym- 
physis. The cervix was still long, but the mouth was less patulous, 
and the probe would not pass more than two and a half inches. 

Since the commencement of treatment the bloody discharge has 
not indicated a menstrual flow. In fact, the bloody discharge became 
progressively less, until it had entirely ceased about the middle of 
August. 

The patient's health greatly improved, and she was permitted to 
return to her home in the country. She wrote me on the 1st of 
September that she still suffered pain, and the discharge still con- 
tinued, but that it now had the appearance of pus, and was somewmat 
fetid for the first time. In October she wrote me again to say that 
there was no sign of the tumor; she had no pain and never enjoyed 
better health. She had menstruated twice since she had returned 
home, but the discharge at both periods was moderate, and she had 
no pain. She continued the ergot up to the middle of September. 

Mrs. Arthur King, of Sterling, Illinois, called on me December 
13th, 1875. She was thirty-five years old, married, and had never 
been pregnant. 

On the 1st of the preceding June she noticed a circumscribed hard 
lump two inches below and to the left of the umbilicus. She was the 
subject of serious uterine and sympathetic symptoms, for which she 
had at different times had treatment. She had profuse menorrhagia, 
leucorrhcea, and great sense of weight in the pelvis. 

Upon examination I found a hard, round, movable tumor, extend- 
ing up to within two inches of the umbilicus, filling up the whole of 
the right iliac, the hypogastric, lower half of the umbilical, and more 
than half of the left iliac regions. 

The contour of the tumor was somewhat uneven, though not dis- 
tinctly nodular. The cervix was long, pointed, and thrown backward 
and to the left. The sound entered the small uterine mouth and 
passed upward, backward, and to the left five and a half inches. 

The diagnosis was a fibrous tumor of the right anterior wall of the 
uterus. I prescribed thirty drops of Squibb 's fluid extract of ergot 
to be taken three times a day. She went home, but did not commence 
taking the medicine until the 20th of December. On the 26th of 
December Dr. J. B. Crandall was called to see her, and describes her 
condition as follows: 

"The patient was in a state of great nervous prostration, and worn out by severe 
pain and loss of sleep. The pains commenced soon after taking the second dose of 
ergot, and were excruciatingly severe for about three hours, after which they con- 
tinued less severely for two days and nights. She had more or less hemorrhage from 



cases. 639 

the uterus after taking the ergot. Her pulse was feeble, 110 to 120 to the minute. 
The skin was hot and dry, and she complained of great pain and tenderness over the 
nterns and lower bowels. The feet were drawn up, and the face wore a pinched and 
peculiar expression." 

Under these circumstances the doctor administered anodynes, tonics, 
and nourishment, to the great relief of the patient. 

On January 11th, 1876, the patient began to pass from the vagina 
small masses of fibrous substance, from the size of a chestnut to that 
of an English walnut. The substances thus discharged were firm 
and gray in color, and were exceedingly fetid. This discharge con- 
tinued up to the 21st of January, when the uterus was very much 
diminished in size, the tenderness had subsided, and the patient ap- 
peared comparatively comfortable. Up to that time she had taken 
but three doses of ergot, on the 20th of the preceding month, and the 
doctor ordered it to be resumed again. This time the ergot produced 
no pain, and after three or four days was discontinued. From the 21st 
of January there were no more pieces discharged, but up to February 
1st a yellowish, thin, offensive fluid passed from the vagina in con- 
siderable quantities. On the first day of February the ergot was again 
ordered and continued two weeks, when, as no results ensued, it was 
finally dropped. 

Dr. Crandall states that on the 14th of February the uterus was re- 
duced to its normal size, and on the 26th the patient was up and about 
her work, completely cured. He remarked, in this connection, that 
the first three doses of ergot taken by the patient was the cause of her 
recovery. 

This case is published in the August (1875) number of the Chicago 
Medical Journal and Examiner, as reported by Dr. Crandall. 

Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the 
anterior wall of the uterus, which, with the enlarged uterus, arose to 
within two inches of the umbilicus. 

She commenced taking thirty drops of the fluid extract of ergot on 
the 22d of Septemper, 1876, and was to increase gradually the dose' 
with the object in view of causing the disruption and expulsion of the 
tumor. The ergot at first produced no perceptible effect until she had 
taken it ten days, when she began to experience the pain of contrac- 
tion. The pain became so severe and continuous that it was necessary 
to omit it for two or three days at a time. The patient was intelligent 
and understood the object and mode of action of the ergot, and when 
the pain entirely subsided, she courageously resumed it in the smaller 
doses, and increased again until the pains became intolerable. On 
the 13th of January, 1877, small pieces of the tumor showed them- 
selves in the vaginal discharges, and by the 26th of the same month 
the whole of it had been discharged piecemeal. 



640 FIBKOUS TUMORS OF THE UTERUS. 

She wrote me on the 30th of January, saying : 

"I think I wrote one week ago to-day. At that time the tumor was passing. It 
continued to pass until the 26th, when, I think, the last was expelled. To-day I send 
you by express a portion of the last that came. I think the whole of it, including the 
portion I sent you, would have weighed one and a half pounds. I do not believe a 
quart can would hold it if the whole had been preserved. It commenced to come on 
Saturday, and from Saturday evening to Sunday morning there was a pint or more. 
After that, the stench was so disagreeable that we could not cleanse it, consequently 
we threw it away. Wednesday and Thursday it seemed to be in one continuous mass. 
I cannot better describe it than to say that it came like sausage-meat from a stuffer. 
I would cut off about four inches a day, that is on Wednesday and Thursday. On 
Friday morning the last of it came away." 

During, and for some days after, the expulsion she suffered slight 
symptoms of septicaemia, but recovered from them, and in the course 
of a month afterward she visited me, when I found the uterus meas- 
ured two inches and a half in depth. She then had some leucorrhoea, 
but was fast regaining her health. She is now perfectly well, and has 
passed in safety the menopause* 

The following case is reported to me by letter by William Fox, M.D., 
of Milwaukee, January 19th, 1880 : 

"Mrs. B., aged forty-three; last child four years old; did not get up well. Men- 
struation returned earlier than usual, and gradually became more frequent and pro- 
fuse, and of longer duration. Finally the abdomen began to enlarge so much that her 
friends believed her pregnant. But her health began to fail ; her losses became 
greater, and almost continuous. She was without treatment, as she believed her con- 
dition due to her time of life. An examination revealed a uterus as large as at the 
sixth month of gestation, and could be easily felt and moved through the abdominal 
walls. A sound entered five and a half inches, and with it in the uterus and the hand 
outside, a tumor could be felt in the anterior wall. The patient was put upon 30-drop 
doses of Squibb's extract of ergot, four times daily, and sent to consult Dr. By ford, 
February 3d, who confirmed the diagnosis and approved the treatment, and made a 
prognosis more favorable than I believed. He said, with the above treatment we 
would starve the growth, and possibly expel it. The period was detained a week, 
when it came on ; February 21st, five weeks from the commencement of treatment, 
with a great deal of pain. The ergot was continued, the pain increasing, until, on the 
third day, I found the patient with a temperature of 105°; pulse, 140, an offensive 
discharge, and complaining of a feeling as of some foreign body in the vagina. The 
vagina was full of a stinking mass, not unlike a placenta in feel, but harder. The os 
was quite open, and the fingers could readily pass into the uterus and describe the 
growth. All the gangrenous mass was taken away as fast as possible with the fingers 
and forceps, and the uterus carefully washed out with carbolized hot water every four 
hours. The ergot was discontinued because of the pain. Whiskey, quinine, and 



* This case, the abstract of which I have here given, was in the May 15th, 1877, 
number of the Archives of Clinical Surgery, N. Y. 



SUMMARY OF CASES CURED BY ABSORPTION. 641 

milk constituted the treatment. She rapidly improved, and in less than a month was 
out driving, walking, and feeling well. In six weeks, menstruation returned ; came 
on without warning ; lasted less than three days ; the first natural period she remem- 
bers having had in four years. She has had three since, perfectly natural in every 
way. She is perfectly well." 

I have known ten eases in which the tumors were expelled piece- 
meal by ergot, with but one death. The death occurred in a patient 
who rode one hundred and fifty miles on a railroad train to see me, 
with pieces of the tumor hanging from the vagina, which she would 
not allow her physician to remove. When she arrived, I passed my 
fingers up into the contracted capsule and scooped out the remaining 
portion of the tumor. She was so exhausted, however, by the journey 
and the sepsis, that she died three days afterwards. 

I cannot help believing that if she had remained at home and sub- 
mitted to the treatment of her physician, her life need not have 
been sacrificed. 

Summary of Cases cured by Absorption. 

The total number of cases here cited is one hundred and one. 
Twenty-two of them are reported cured. In thirty-nine more the 
tumors were diminished in size, and the hemorrhage and other dis- 
agreeable symptoms removed. Nineteen of the remainder were bene- 
fited by the relief of the hemorrhages and leucorrhceal discharges, 
while the size and other conditions of the tumors were unchanged. 
Out of the whole number only twenty-one cases entirely resisted the 
treatment. This shows results decidedly favorable in eighty of the 
one hundred and one cases. 

We may still further appreciate the favorable effects of the treat- 
ment by the consideration that in twenty-one cases it was suspended,, 
which is as great a number as resisted treatment. 

It is also a noticeable fact that some of the cases in which the treat- 
ment was suspended were very much benefited by it. 

I have no doubt that many more cases of fibrous tumors of the 
uterus treated by ergot might have been collected had time permitted, 
as I have heard of cases the history of which I could not obtain. 

In collating my cases, I have in no way selected or arranged them 
to influence inferences as to results, but I have faithfully recorded all 
I have received from correspondents, or found in journals, which 
were given sufficiently in detail to enable me to arrive at a correct 
idea of the treatment and its effect. 



41 



642 



FIBROUS TUMORS OF THE UTERUS. 



Hildebrandt.. 
Bengelsdorf . . 

Chrobak 

Atthill 

White 

Goodrich 

Howard 

Jackson 

Etheridge 

Merriman 

Fisher 

Morris 

Buckingham. 

Cowan 

Dean 

Wey 

Hodder 

Jukes 

Warner 

Bvford 

Allen 

Thomson 

Russell 



Total 



32 
XL 

o 

o 

6 


•6 

0) 


minution ii 
ize of tumo 
nd cure of 
lemorrhage. 


0) = ■ 

.cos 


1 


^ 


O 


fi™"^ 


w M 


£ 


27 


3 


11 


9 


4 


4 






2 


2 


9 


1 


2 


3 


3 


3 






2 


1 


14 


4 


5 




5 


1 


1 








2 


2 








8 


2 


3 


2 


1 


1 


1 








4 


2 


2 






1 


1 








1 




1 






1 








1 


1 




i 






2 




2 






1 




1 






4 


1 


3 






1 


1 








2 








2 


9 


3 


3 


1 


2 


1 




1 






3 




3 






1 




1 






101 


22 


39 


19 


21 



While I could add to the number of cases contained in this table, 
they would not affect the deductions from it, 

Modes of using Ergot. 

Not much uniformity has been observed by the writers above quoted 
in the manner of using ergot. 

Drs. Hildebrandt, Bengelsdorf, Chrobak, Atthill, and Jackson recom- 
mend, and use it hypodermicallv. 

Drs. White, Jenks, and Howard administer it hypodermicallv, inter- 
nally by the stomach, and in the form of suppositories in the vagina 
and rectum. 

Some of the arguments in favor of the hypodermic injections are: 
1st. It acts more rapidly and with more certainty. 2d. It does not 
produce the gastric disturbances sometimes caused by ergot when 
taken internally. 3d. It can be administered in this way when it is 
entirely impracticable to give it internally on account of the great 
exhaustion or gastric irritability of a patient. 

The main objections to the hypodermic method seem to be: 1st, 
the pain inflicted by the needle; and, 2d, the inflammation and sup- 
puration which ensue. 

Dr. Hildebrandt has met with but one case where the pain of the 



MODES OF USING ERGOT. 643 

puncture was an objection to its hypodermic use. With regard to 
abscesses he says : " I am sure I do not exaggerate Avhen I say that 
up to the present time I have myself made one thousand hypodermic 
injections of ergotin for various purposes, or have seen them made 
and observed their results in the clinical wards in charge of my 
assistants." And he then adds : " I have never seen an abscess fol- 
low the injections made by me personally, and only in three clinical 
cases did this occur. The chief reason why no abscesses formed 
among the large number of other injections is that I always injected 
the fluid very deep into the subcutaneous cellular tissue — perhaps 
even into the abdominal muscles." 

Dr. Atthill met with this difficulty in all three of his cases, although 
he also injects the fluid deep into the tissues. 

Dr. Chrobak was obliged to desist from treatment on this account, 
in four out of his nine cases. 

Dr. Cowan was interrupted in his case by the formation of abscesses. 

Thus it will be seen that much difficulty is experienced by many 
in carrying out the treatment. 

Dr. Hildebrandt's reason does not seem to be the only one why 
practitioners are so troubled with this objection, since Dr. Atthill and 
others have also injected deeply. As far as I can judge, very few 
have been able, even by the most careful efforts, to achieve the same 
happy results in this respect as Dr. Hildebrandt. 

Dr. Hildebrandt, and also Dr. Atthill, select the lower part of the 
abdomen as the part in which to make the injections: 

Dr. Keating, of Philadelphia, injects just posterior to the great 
trochanter. 

Dr. Jackson selects the deltoid region, and thinks it makes but 
little difference where the insertion is made. 

Dr. White, of Buffalo, injects over the abdomen, into the cervix 
uteri, and into the substance of the tumor if it is accessible, and has 
met with no bad results. 

Dr. Wey used over two hundred injections in the abdominal region 
above the pubes in one case, and abscesses occurred in the seat of the 
puncture as often as once in eight operations. 

Dr. Dean commenced using ergot in the form of Squibb 's fluid 
extract by injecting it into the cavity of the uterus through a flexible 
catheter, but now he employs the solution of Squibb 's solid extract 
dissolved in water — one grain to five minims. Of this he injects from 
ten to fifteen drops into the substance of the cervix about four times 
a month or once a week. He thinks the effects are more prompt and 
energetic than when administered hypodermicalty. His instrument 
consists of a barrel the same size as the common hypodermic syringe 
and a tube six inches long. He has known inflammation and sup- 
puration to follow but once in his whole experience. 



644 riBKOus tumors of the uterus. 

Different Preparations. 

Believing the preparation of the medicine employed had much to 
do in causing the irritation thus observed, efforts have been made to 
find some form that would not produce the painful results thus de- 
scribed. 

Hildebrandt is now in the habit of using Dr. Wernich's formula 
for the watery extract of ergot, and Dr. Munde thinks it is very simi- 
lar to the preparation made by Dr. Squibb. Dr. Hildebrandt added 
pure glycerin in the proportion of about one part to four of the solu- 
tion, and the amount of the injection was forty minims. This con- 
tained a little over two grains of the extract, probably representing 
ten to twelve grains of the crude ergot. 

Most American practitioners now use Dr. Squibb 's preparation 
above referred to, some of them by dissolving it in pure water, while 
others add to the water a small amount of pure glycerin. Dr. Squibb 
recommends a solution of this extract as follows : Dissolve two hun- 
dred grains of the extract in two hundred and fifty minims of water 
by stirring ; filter the solution through paper, and make up to three 
hundred minims by washing the residue on the filter with a little 
water. Each minim of this solution represents six grains of ergot in 
powder. Of this solution from ten to twenty minims are injected 
once daily, or once in two days. This is the only preparation I have 
used in hypodermic injections, and I believe it the best we can at 
present procure. 

Dr. Wey properly lays great stress on the necessity of having the 
solution fresh, believing that in a very short time it deteriorates, and 
becomes more irritating to the tissues. He says : " Ergot thus ad- 
ministered generally produces, prompt effects." In most instances, 
in half an hour the patient experiences painful contractions of the 
uterus. The hand applied over the organ at once recognizes the in- 
creased hardness in the mass. These contractions increase in severity 
for the first two hours, and then continue with vigor for from six to 
ten hours, gradually becoming less until they cease entirely. Some 
patients suffer so much from these pains as to refuse to proceed in 
the treatment, while others bear them without much inconvenience. 
We do not always observe these painful effects even when the drug 
operates very beneficially. Sometimes the hemorrhages are controlled, 
as it were, insensibly, and the tumor slowly decreases in size without 
the patient experiencing any considerable discomfort. It seems highly 
probable, from the statements made by my correspondents, and espe- 
cially Dr. Wey, as well as my own observations, that the benefits of 
the remedy are produced with more rapidity in the early part of the 
treatment. 

The preparation used internally more frequently than any other is 



DIFFERENT PREPARATIONS. 645 

the fluid extract, either alone or in combination with belladonna. 
Each minim of Squibb's fluid extract is equal to one grain of ergot. 
Some recommend that it be given in doses of thirty drops three or 
four times a day. Others believe that it should be given in larger 
doses less frequently repeated, as, for example, one drachm once or 
twice in twenty-four hours. It is efficacious given in either way, but 
probably more so in the larger and less frequent doses. This prepara- 
tion is so offensive, and causes so much nausea in exceptional instances, 
that it cannot be borne. 

Dr. Squibb claims that his solid extract does not offend the stomach 
so frequently as the fluid extract. This extract may be used in pills 
coated with gelatin. A pill of five grains is equal to twenty grains of 
the crude ergot, and may be administered twice or three times daily. 
From observation of the effects of the different preparations, I am 
satisfied that this is altogether the most efficient and agreeable for 
internal administration. 

A suppository for the rectum, which, in Dr. White's practice, acted 
satisfactorily, may be composed of fifteen grains of the solid extract, 
and enough gelatin to give it size and form. I have no doubt of the 
great usefulness of this method of administering ergot. 

I think it is also quite certain that the addition of belladonna in 
some cases increases the curative effects of ergot ; how much, I am 
not quite sure. Dr. Goodrich, who reached such splendid results, 
gave the fluid extract of ergot and belladonna together throughout 
the entire treatment of his case. 

From what has been said it may be inferred that hypodermic in- 
jection, if the most efficacious, is also the most objectionable method 
of using the ergot, and that in many cases the exhibition of it in this 
way is rendered entirely impracticable, because intolerable, to the 
patients. 

May we not hope for great improvement still in the pharmacy of 
ergot? Ergot produces many good effects besides reducing the size 
of the tumors and relief of hemorrhage. I have seen, and some of 
my correspondents mention, great functional improvement in the 
more important organs. Some patients are relieved by it of obstinate 
constipation ; the appetite is improved, and the general health restored. 
This remarkable salutary effect is obviously due to its action on the 
ganglionic nervous system. In exceptional instances ergot has very 
disagreeable effects. Dr. Goodrich mentions inflammation of the 
uterus as one, and my patients often complain of great heat and 
tenderness in the uterine region. Hildebrandt speaks of one case in 
which, after the sixth injection, the patient complained of vertigo, 
imperfect control of her lower extremities, and. slight spasms of the 
flexor muscles of the forearm. Dr. Wey observed severe general 
nervous perturbation to follow its use in one instance. And Dr. 



646 FIBROUS TUMORS OF THE UTERUS. 

Morris's patient discontinued treatment because of the terrible and 
tumultuous effects upon the uterus. 

Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of a 
very interesting case of fibrous tumor treated by hypodermic injec- 
tions of ergot, in which phlebitis supervened. A condition of one 
limb was produced precisely similar to phlegmasia alba dolens, and 
ran its protracted course to a favorable termination. Prior to the 
accident the tumor had very much decreased in size , but, after the 
treatment was suspended, and during the course of the phlegmasia, 
it rapidly increased again, and the hemorrhages which had been con- 
trolled returned. After trying other methods of treatment without 
any good results, he and his patient in despair were driven to the use 
of ergot again. It was tried internally with some good effects, but as 
the remedy thus administered disagreed with the stomach, it was again 
injected hypodermically with rapid improvement. The injections 
were used on the side of the abdomen, opposite to that formerly 
affected with phlebitis. After a number of injections, signs of in- 
flammation of the veins were again observed, and the sound leg 
passed through all the stages of ]3hlegmasia that had been observed 
in the first. From the intelligent observation of Dr. Wey and others, 
we may fairly conclude that it is not improper to continue the use of 
ergot during the menstrual flow. I can also add my testimony as to 
its entire harmlessness when given during that periodical flow. 

Auxiliary Treatm eat. 

With the exception of Drs. Goodrich and Howard, all the writers 
and correspondents quoted have depended exclusively on ergot for 
the removal of fibrous tumors of the uterus ; in fact, the treatment has 
been experimental, and had for its object the solution of the question 
suggested by the publication of Hildebrandt's articles on the use of 
ergot, viz. : Will ergot cure fibrous tumors of the uterus ? The course 
pursued was well calculated to, and I think did, test Hildebrandt's 
treatment pretty thoroughly, but it is doubtful whether this exclusive- 
ness is the best practice. The well-known alterative and sorbefacient 
medicines have, in rare instances, been credited with the cure of these 
tumors without the aid of ergot, and it is not difficult to understand 
that absorption may be promoted with more certainty by the alkaline 
bromides and iodides, where the vitality of the tumor is first impaired 
by the action of ergot on its vessels and the muscular fibres surround- 
ing it. Dr. Goodrich seems to have held this view of the alterative 
treatment, as he prescribed iodide of potassium and bichloride of 
mercury with ergot. Dr. Howard also employed alteratives in the 
same way. Both of these gentlemen combined belladonna with 
ergot. The efficiency of this combination, as represented by their 
reports, justifies us in believing that the alteratives employed by them 



CORRECTIVE TREATMENT —MODUS OPERANDI. 647 

were auxiliary in a high degree. How much may be effected by ju- 
dicious alterative and other auxiliary treatment will, doubtless, be 
determined by future observation. 

Corrective Treatment. 

By this I mean treatment that will prevent or ameliorate the dis- 
agreeable effects of ergot in certain exceptional instances. The dis- 
tressing pain caused by it may sometimes be made more tolerable by 
the administration of hydrate of chloral, without very materially in- 
fluencing its other effects. Indigestion, constipation, hydremia, and 
nervous debility may be corrected by tonics, alteratives, laxatives, and 
stimulants given simultaneously with ergot. In short, the general 
condition of the patient should be cared for in the same rational 
manner as if ergot was not being administered. 

Modus Operandi. 

The influence of ergot over the uterus has been a familiar fact to 
the profession for a long time. It is not long, however, since we were 
aware of its effects upon the muscular fibres entering into the forma- 
tion of other organs. We now know that this medicine acts upon the 
unstriped muscular fibre wherever founds whether in the viscera or in 
the vessels of the body. 

The fibres of the uterine walls, and the arteries supplying them 
with blood, both belong to this class ; this fact in the formation of the 
uterus renders it particularly susceptible to the action of ergot. The 
drug acts upon the uterus in a threefold manner, and causes a dimin- 
ished flow of blood to the morbid as well as healthy tissues in the 
uterine structure. 

1st. The calibre of the arterial tubes is diminished by the contrac- 
tion of the muscular fibres which enter into their composition. 2d. 
The arterioles are diminished in size by compression from the con- 
traction of the uterine muscular fibres which surround them. 3d. 
These vessels are distorted and drawn in diverse directions by both 
the contraction and compression, and hence are rendered less fit for 
sanguineous conduits. 

Another consideration of prime importance is that, under the influ- 
ence of these medicines, the nutrition of fibrous tumors is interfered 
with, not only from diminution of blood in their tissues, but also from 
compression of their substance by the proper fibres of the uterus, their 
trophic energies are arrested, and are therefore made more susceptible 
to the process of disintegration and absorption. 

The great influence exerted by ergot over the circulation of the 
uterus is rendered more efficacious in the removal of fibroid tumors 
of that organ, because of the peculiar organization of the growths. It 



648 



FIBROUS TUMORS OF THE UTERUS. 



is now pretty well understood that this neoplasm is not very gener- 
ously supplied with arterial blood, and that its supply is derived from 
numerous minute vessels instead of one or two of larger calibre. From 
these circumstances it results that its vitality is very low, its circula- 
tion easily disturbed, and consequently its nutrition impaired. 

I think we are justified from observation in assuming that the action - 
of ergot may be graded from an almost imperceptible to a very intense 
degree. Probably the first degree affects the vascular supply; the 
second, in addition to this, causes so much contraction as to merely 
render the fibres tense without causing pain ; and the third prompts 
the uterine fibres to vigorous and painful contraction. 

This inference is plainly deducible, I think, from the several modes 
by which tumors are made to disappear under its action, as well as 
from direct observation of the uterine fibres. 

I will now venture to call attention especially to the manner of ex- 
pulsion of the polypoid and submucous intramural varieties. It will 
be seen from Fig. 286 that when the uterus contracts, all the fibres 



Fig. 286. 



Fig. 287. 





Fibroid Polypus. 



Submucous Fibroid Tumor. 



unite in pressing the polypus through the cervical canal, which is 
usually already shortened, and rendered dilatable in consequence of 
its increased vascularity. 

The cervical canal dilates, and after more or less painful efforts the 
polypus is expelled entire, covered by the mucous membrane. This 
membrane is often in a state of gangrene, but so far as I have observed 
these cases, the tumor is not broken to pieces. 

Fig. 287 represents an intramural fibroid between the central line 
of the uterine wall and the mucous membrane. It is intended to 



MODUS OPERANDI. 649 

show a tumor where a thin layer of fibres separate it from the mucous 
membrane, and how a thick and heavy layer is spread over its exter- 
nal hemisphere. Three-quarters of the thickness of the muscular wall 
are applied to that side of the tumor. If in this position all the fibres 
of the uterus vigorously contract, the fibres near the mucous mem- 
brane must be overcome by the heavy layer outside (at c). But the 
opposite wall of the uterus plays an important part by supporting the 
weaker layer at the fundus of the tumor, and adding its own force in 
overcoming the capsule (at e), where it usually gives way. The posi- 
tion of the tumor makes its escape from the concentric action of all 
the fibres of the uterus impossible, and every one knows that when 




Sub-peritoneal Fibroid Tumor. 

the resistance is partially overcome, the uterus is stimulated to more 
vigorous action, and the pains will not abate until the mass is ex- 
pelled. If not too large, it is driven out without undergoing great 
laceration, but if its size and attachments are such as to make this 
impracticable, it will be broken into fragments and expelled piece- 
meal. 

Allow me to supplement the above description by explaining the 
effect of ergot on the sub-peritoneal and central intramural tumor. 
In Fig. 288 we see the disposition of the fibres on the sub-peritoneal 
variety ; next the uterine cavity there is a thick and strong stratum 
of fibres, while immediately under the peritoneum the layer is very 
thin and comparatively weak. When the uterus is acting with vigor, 



650 FIBROUS TUMORS OF THE UTERUS. 

the fibres between A and B will cause those two points to approxi- 
mate each other, and the tumor will become pediculated ; but that is 
all, for the tumor lays outside the field of concentric action and escapes 
the crushing influence to which the submucous variety is subjected. 
The amount of force exerted upon it is that exercised by the weaker 
layer of fibres in a state of conquered antagonism, and the rupture of 
the capsule is impossible. 

If we take Fig. 289 as a correct representation of the fibrous tumor 
when situated in the central stratum of fibres, in which the antago- 
nism is equal at all points, it will be evident that there is no ten- 
dency to rupture of the capsule, and much less crushing influence 
exerted upon it than if it were situated slightly nearer the mucous 
membrane. 

Fig. 289. 




Intramural Fibroid Tumor. 

This variety of the tumor, therefore, yields to the influence of ergot, 
only as it may be " starved out " by diminution of its blood supply, 
and as the effect of pressure, which we all know are the two conditions 
most favorable to absorption. 

Now I think we have arrived at a point in this investigation where 
we can draw inferences as to the forms of tumors likely to be affected 
by ergot in different ways, as well as those that will not be affected 
by it. 

We do not expect ergot to cause painful and efficient contractions 
in the healthy unimpregnated uterus ; its fibres are not capable of 
such contraction, and it is not until the fibres have become greatly 
developed that they are susceptible to the impressions of ergot. In 
cases of early abortion, its action is very unreliable, but after the 
fourth month of pregnancy it acts quite efficiently. 

In tumors of the uterus, the development of the fibrous structure 



MODUS OPERANDI. 651 

is sometimes so slight that it is incapable of contraction ; there may 
be so many nuclei of degeneration that there are not enough sound 
fibres left for efficient contraction. Then, where there are many 
small tumors developed in the uterine walls, the circulation is cut off 
to such a degree that they degenerate into a cartilaginoid substance, 
and sometimes they are infiltrated with calcareous material. In none 
of these cases will ergot cause any appreciable results. When, how- 
ever, there are but one, two, or three nuclei of morbid growths, as 
they increase in size the fibres undergo the development necessary to 
enable them to contract with great efficiency, and render them sus- 
ceptible to the influence of ergot. 

Another condition which influences the hypertrophic growth of the 
fibres is the situation of the tumor. 

Subperitoneal tumors do not cause as great growth in the fibres of 
their neighborhood as the intramural or submucous varieties. A 
single intramural tumor causes great development of the whole uterine 
tissues, but the development of the wall in which it is situated de- 
cidedly predominates. The submucous neoplasm so soon gains the 
uterine cavity that the development is nearly the same in the whole 
organ. 

When, therefore, we administer ergot for the cure of fibrous tumors 
of the uterus, the beneficial action of the drug will depend upon the 
degree of development of the fibres of the uterus, and the position of 
the tumor with reference to the serous or mucous surface. The nearer 
the mucous surface, the better the effects. If the tumor is very near 
the lining membrane, we may hope for its expulsion en masse, or by 
disintegration. 

We can often select the cases in which good results may be expected. 
There are four conditions which are usually reliable for this purpose. 
They are : smoothness of contour, hemorrhage, lengthened uterine 
cavity, and elasticity. A smooth, round tumor denotes, for the most 
part, uniform textural development, hemorrhage, a certain proximity 
to the mucous membrane, a lengthened cavity, great increase in the 
length and strength of the fibres ; and elasticity assures us of the fact 
that cartilaginoid or calcareous degeneration has not begun in the 
tumor. 

An uneven, nodulated tumor may be composed of many separate 
solid masses. These displace and prevent the growth of the fibres to 
such an extent as to render contractions inefficient. When hemor- 
rhage is not present, the tumor is probably near the serous surface, 
and consequently not surrounded by fibres. A short cavity denotes 
short, undeveloped fibres, while hardness is indicative of unimpress- 
ible induration. 

Although I have no experience in the use of ergot in such cases, I 
should expect large fibro-cystic tumors to resist its action. 



652 FIBROUS TUMORS OF THE UTERUS. 

From this view of the subject, it will be seen that I freely admit that 
there is a large number of cases in which ergot cannot produce any 
good results in consequence of their nature. Another reason of equal 
moment why ergot may fail to act upon such cases as would seem to 
be favorable, is the worthlessness of. the drug and its preparations. 

Dr. Squibb, of New York, a high authority, says in reference to this- 
subject: 

"The molecular constitution of the active portion of the drug seems, however, in its 
natural condition to be loose, and, like a slow fermentation, to be undergoing slow 
molecular changes, so that by age its peculiar .activity is slowly diminished until 
finally lost." 

And again : 

" The ergot in the grain, however well kept, is known to become inactive without 
any known change in appearance, though the sensible properties, such as odor and 
taste, may and probably do not change. Ergot, in powder, is known to diminish in 
activity much more rapidly than when in grain, and probably soon becomes inert. The 
tincture and wine of ergot are believed to change, though more slowly than the ergot 
in substance ; while the extracts, and so-called ergotins, are all supposed to change 
more rapidly." 

These facts, so explicitly stated by Dr. Squibb, are very sugges- 
tive as to the causes of the frequent failures of ergot, and need no 
comment. 

When all these causes of failure are considered, the variety of ex- 
perience met with in the reports upon its trial in the treatment of 
these tumors is not surprising. It should not, however, be discour- 
aging, but should prompt us to more care in selecting the cases and 
securing reliable preparations of ergot. I have implicit faith in the 
action of ergot when all the conditions I have pointed out are present. 
I do not believe it to be uncertain in its action. 

In addition to the above conditions, I believe perseverance an in- 
dispensable condition to success, as it often requires several months 
to get the best results. 

In concluding, I desire to disclaim any expectation that ergot will 
supplant other modes of treatment. The expert surgeon will, as he 
always has, use his instruments to the neglect of remedies less sum- 
mary in their effects, and in his hands the maximum of safety will 
obtain ; but there are very few general practitioners who ought, or 
would be willing, to undertake enucleation of fibroid tumors of the 
uterus. I do claim, however, that the judicious gynecologist will 
lose fewer patients, and make more cures, by the consistent adminis- 
tration of this medicine than can be looked for from surgery. 

I am surprised that others who have written upon the subject 
should be so incredulous as to the effect of ergot, and the only way 
I can account for it is what, I think, I can see in their practice as 



MODUS OPERANDI. 653 

related by themselves, viz., that they do not give it a fair trial. They 
fail to give it in large enough doses and persevere long enough in its 
use. The treatment of some of my successful cases extended over 
many months. When the pains that indicate efficient action, and 
always precede disruption and expulsion occur, the practitioner gen- 
erally becomes alarmed, gives anodynes, and withdraws the medicine, 
thus abandoning the case, and declaring that ergot is a dangerous 
remedy. If he had witnessed the same, or even severer, pains in 
labor, he would have encouraged them, and so he should do in ex- 
pelling the tumor, and the result would be a safe delivery. The 
tumor would be expelled and the patient relieved. 

Before drawing my remarks on the use of ergot to a close allow 
me to mention some of the queries that have arisen in my own mind, 
or have been propounded to me by medical men. If the ergot acts 
so powerfully in expelling submucous tumors, is there not danger that 
it may rupture the capsule of the subserous variety, thus expelling 
them from the uterine substance into the peritoneal cavity, and en- 
danger the life of the patient by causing peritonitis ? A proper con- 
sideration of the conditions existing in such cases will justify my 
answering this query in the negative. There is a great difference in 
the influence exerted by the uterine fibres on the two varieties of 
tumors. In the submucous variety the whole power of the uterine 
contractions is exerted toward the tumor, driving it in the direction 
of the os uteri. When the tumor is subserous the contractions are 
from the axis of the tumor, and their effect is merely to render it 
pedunculated, and lessen the vascular supply going to it. The main 
effect, therefore, will be to check the rapidity of its growth, or to 
prevent its further enlargement altogether. This statement will suffi- 
ciently explain the effects of the medicine upon this variety of these 
morbid growths. Another question is, does the long-continued ad- 
ministration of ergot induce the gangrene of the extremities, that has 
been attributed to it? And still another, does it cause inconvenience 
or danger by affecting seriously the nervous centres ? After having 
given this remedy in frequently repeated and large doses, and ob- 
served its effects with great care for a number of months consecu- 
tively, I can say that I have not noticed any such consequences. I 
am not prepared to assert that there is, and always will be, immunity 
from such effects. The worst symptoms I have witnessed are the 
severe and persistent pains, and the apparent inflammation of the 
uterus and peritoneum, where its action has been excessive. These 
symptoms, however, have been invariably controlled by proper treat- 
ment, and have in no instance proved disastrous. In other cases, 
when the tumor was slowly disintegrated and expelled, a moderate 
form of septicaemia has invariably occurred ; but this condition has 
not been sufficiently grave to excite alarm in my mind. 



654 FIBROUS TUMORS OF THE UTERUS. 

A simultaneous employment of sorbefacients and the administra- 
tion of ergot would, doubtless, in some cases prove more efficacious 
than either alone. But I am free to confess that this conclusion, so 
far as I am concerned, is arrived at more from therapeutic inference 
than observation. As I am giving the results of my own observation, 
more than those derived from the research of others, I deem it but 
fair to state that I have not given this combined method of treatment 
an extensive trial. 

We should remember, in the employment of any course of treat- 
ment for the cure of these fibrous tumors, that reliable results are not 
to be obtained without the long-continued use of the remedies, and a 
thoughtful management of them in individual cases. And I must 
say, in this connection, that I believe a want of these considerations 
has led to mu£h false experience. The treatment of fibrous tumors, 
located in other organs than the uterus, will not serve as a useful 
guide in the management of the uterine neoplasm. The same con- 
ditions do not exist elsewhere. The tumors are nowhere else sur- 
rounded with muscular fibres whose action can be commanded by any 
remedy within our knowledge. Whether the observation of the pro- 
fession at large will or will not at present bear me out in my earnest 
belief in the curability of some of these tumors by the means I am 
now teaching, I do not know ; but I am sure that there is so much 
logic in the method that it deserves a much more extensive trial than 
has hitherto been made of it. 



Treatment by Electricity. 

Recently the treatment of uterine myomata by electrolysis has re- 
ceived considerable attention. The pioneers of this method were Drs. 
Cutter, Kimball, and Brown. At a meeting of the American Medical 
Association in this city, Dr. Cutter illustrated his method of operat- 
ing. He uses electrodes invented especially for this purpose. They 
are spear-shaped and mounted upon handles, in order that they may 
be directed with the more certainty, and made to penetrate hard, 
fibrous growths without deviating from their intended course. The 
blades are five and one-half inches long, and are insulated to within 
nearly one inch of the point. Two of these electrodes are inserted 
through the abdominal wall into the substance of the tumor, the 
points being separated by a space of several inches. Through these 
electrodes a galvanic current is passed, the electricity being generated 
by eight pairs of carbon and zinc plates, excited by saturated solu- 
tion of potassic bichromate and sulphuric acid, one part of the former 
to two of the latter. The time allowed at each sitting varies from 
three to fifteen minutes. It was said that this operation did not pro- 
duce much pain, and was usually followed by a copious flow of urine. 



TREATMENT BY ELECTRICITY. 655 

The number of operations for the individual cases varied from one 
to nineteen, and the intervals between them from a day to two months. 
In certain desperate cases this seems to me to be a valuable resource. 

ApostoWs Method. 

In 1882 Apostoli* began using electricity for these tumors in a 
somewhat different but apparently no less efficacious manner. In- 
stead of puncturing the abdominal walls, he places one pole over the 
abdomen and another within the uterus. When the uterus cannot be 
sounded he punctures the tumor either from the vagina or from the 
highest available point in the cervical or uterine cavity. The external 
electrode is made of a thin layer of wet potters' earth spread over the ab- 
domen so as to lie in intimate contact with the skin over a surface about 
twelve inches in diameter. This enables him to use a current of 100 
milliamperes without harm or inconvenience to the patient. In 1887 
Dr. F. H. Martin,f of Chicago, constructed an abdominal electrode of 
animal membrane with which he has used 300 to 400 milliamperes. 

The internal or active electrode is the isolated end of a platinum or 
gold sound, and acts upon the entire length of the uterine cavity, or 
upon the canal made in the substance of the tumor by a sharp-pointed 
electrode. He employs as strong a current as the patient can bear 
without discomfort, and continues it from one or two minutes to 
twenty, or an average of five to ten, and maintains that a mild current 
of longer duration does not have the same effect. With these large 
external electrodes the strength of the current is determined by the 
effect produced at the internal. From 100 to 150 milliamperes is the 
maximum intensity that can be tolerated with an ordinary internal 
electrode about three inches in length. When the internal electrode 
can be made longer or larger the intensity may be made still greater. 
In all cases it is, however, necessary to commence with a mild current 
and increase its strength gradually. 

The treatment is continued until the patient is relieved of all 
symptoms referable to the tumor, and sometimes longer. The average 
number of treatments is from twenty to thirty, although sometimes 
not half that many, sometimes many more, may be required. The 
removal of large tumors is not usually attempted. after the symptoms 
are relieved, as that requires more time than the patient, and probably 
the physician, cares to spend in the trial. Nevertheless, some of the 
small ones have disappeared and many large ones have become 
smaller. 

The best time for the application is between the menstrual periods 

* Traitement Electrique des Turaeurs Fibreuses de l'Uterus, L. Carlet. 
f Treatment of Fibroid Tumors by Electrolysis. Jour. Am. Med. Ass'n, April 
23, 1887. 



656 FIBROUS TUMORS OF THE UTERUS. 

and while the uterus is not bleeding, although Apostoli sometimes 
makes them for the purpose of checking existing hemorrhage. 

Modes of Action, 

It is difficult to determine just how electricity acts in these cases, 
but it probably acts in several different ways. The fact that the 
tumors are of a low grade of vitality, and that they are surrounded by 
muscular tissue easily brought into action, renders them subject to an 
arrest of growth from comparatively slight causes. Their intimate 
connection with the nutritive changes of the uterus also has much to 
do with their growth and decay. 

The following are perhaps the principal kinds of action produced 
by the electricity : 

1. The excitement of inflammation in the substance of the tumor, interfer- 
ing with its nutrition and producing absorption of its degenerated 
elements. This is probably the manner in which the applications 
formerly made by Cutter, Brown, Kimball, T. G. Thomas, Baker, and 
their followers, act. 

2. The electric current is supposed, in these low forms of tumor, to 
have an electrolytic action, breaking up the chemical combinations so 
that the acids accumulate about the positive pole and the bases about 
the negative, and are thus cast off and absorbed. Just how this can 
occur to any considerable depth in living tissue without destroying 
its life along the course of the current, any more than the stomach can 
digest itself, would, however, seem incomprehensible. 

3. A chemical or caustic action is, however, more easily understood, 
and is one of the most important factors in Apostolus method. His 
observations go to show that when the external electrode is connected 
with the positive pole the hemorrhage may be checked. The tissues 
are cauterized and hardened in much the same way as if they had 
been seared by the actual cautery at a low heat. In cases of subperi- 
toneal fibroids without hemorrhage he connects the negative pole with 
the uterine sound and produces sloughing and hemorrhage, and thus 
claims to deplete them. As the explanations are entirely theoretical, 
it is, I think, as reasonable to suppose that the negative pole checks 
the hemorrhage by simple, moderate but deep cauterization and subse- 
quent cicatrization, and that the positive pole diminishes the nutrition 
of the subperitoneal tumors by cauterizing and cicatrizing the uterine 
walls about their bases or pedicles. 

4. Electricity also acts as a poiverful stimulant to uterine contraction, 
and may do so both during and after the treatment without causing 
pain. Such painless contraction occurs after labor, abortion or mod- 
erate uterine dilatation. That this contraction diminishes the vitality 
of the tumor there is little doubt, although it may play but a sub- 



TREATMENT BY ELECTRICITY. 657 

ordinate part in the treatment by electricity. The cauterization also 
acts as a stimulant to contraction in the uterine walls. 

5. A local alterative or atrophizing influence must also be attributed to 
this treatment. The disturbance of such a powerful electric current 
to the organic nerves, and to the vitality of the cell structure, must 
have a decided, albeit a secondary or adjuvant action. 

Dangers Attending its Use. 

The dangers of this treatment are great unless the operator is thor- 
oughly competent and extremely careful. However, a minute study 
of the technique as taught by Apostoli renders his method a perfectly 
safe one to employ. But the puncture of the tumor from the abdo- 
men must always be attended by some danger, and also requires the 
use of an anaesthetic. 

Carelessness in the introduction or isolation of the probe, or in 
making the puncture per vaginam, may lead to disagreeable or serious 
consequences. Sudden interruptions in a powerful current would 
cause serious shock, as might also a sudden increase in its intensity. 
Severe exertions, exposure, venereal indulgence, etc., after a treatment 
must also be guarded against among the careless and less intelligent 
patients. 



42 



CHAPTER XL. 

SURGICAL TREATMENT. 

Removal of Polypoid Tumors. 

The first thing I have to say about the operations intended for 
this purpose is that they should be as simple as possible, compatible 
with thoroughness. It is not necessary to exemplify this idea. It 
is self-evident, and yet often ignored. The most effectual plan of 
avoiding danger is to have a distinct idea of the sources whence the 
danger may arise, and in connection with these tumors dangers may 
arise (1) from laceration, contusion, or other damage to the uterus, 
resulting in hemorrhage or inflammation ; (2) incomplete ablation, — 
the remaining portion producing septicaemia; (3) shock sometimes 
following protracted efforts at removal. This last is a very important 
source of peril. 

These dangers will, therefore, for the most part be proportionate 
to the extent of manipulation and instrumental procedure and the 
incompleteness of the operation. The old operation of tying the neck 
of the tumor, and allowing it to slough away, especially when it was 
situated in the uterine cavity, combined all the causes of danger above 
enumerated except that arising from hemorrhage ; and it is a curious 
fact that this operation was invented for the sole purpose of avoiding 
hemorrhage, which is really the least dangerous of all, according to 
my observation. Indeed, I have never seen serious hemorrhage 
caused by the removal of a polypus however effected. The practice 
of ligating the tumor and then amputating it is to a less degree open 
to the same criticism. 

Torsion or amputation are the methods now usually employed by 
the best gynecological surgeons of the present day, and the first is 
the one I have for several years resorted to in almost every instance. 
Amputation may be performed by the scissors, knife, by the ecraseur, 
or galvano-cautery wire. All possible danger from hemorrhage will 
be avoided by the last means indicated ; but I may state that there 
is scarcely any danger of hemorrhage from the use of either of the 
other instruments. Torsion is performed by seizing the tumor with 
strong vulsellum or fenestrated forceps and twisting the tumor several 
times around and making moderate traction until the detachment 
and removal are completed. In order to amputate a polypus when 
the tumor is partially or wholly expelled from the uterus the tumor 
should be drawn down with one of the forceps mentioned until its 



REMOVAL OF POLYPOID TUMORS. 659 

attachment is brought into view, when with the scissors or the knife 
the neck may be divided as close to the uterine attachment as possible 
without cutting the substance of the uterus ; or the neck of the tumor 
may be surrounded by the ecraseur or galvano-cautery wire and sepa- 
rated by it. A tumor attached to the fundus, or high up in the body 
of the uterus, cannot always be drawn down and amputated in this 
way without causing inversion of the organ, and consequently a knife 
in the shape of the blunt hook in our obstetric case, with an edge 
upon the concavity of the curve, will be necessary. This may be in- 
troduced and guided as nearly as possible to the point of attachment 
by the finger or hand. This process is very much facilitated by a 
piece of twine passed through a small hole in the extremity of the 
hook ; the twine should be long enough to hang out of the vagina and 
give a firm hold. When placed, the convexity of this knife should be 
turned towards the neck of the tumor and a sawing motion executed 
by the handle and twine until the tumor is cut through. 

The chain of an ecraseur may be carried to or near the point of 
attachment by means of two flexible rods with small holes in the ex- 
tremities. The wire is passed through the opening at the ends of the 
rods, and being held closely together they are introduced, carried 
behind the polypus, as high up as possible. One of the rods is then 
held in position while the other is carried around the tumor, thus en- 
circling it by the wire. Sometimes it will be easy to pass the wire by 
drawing a loop of it through the perforated ends of the rods, large 
enough to pass entirely around the lower end of the tumor, and as 
the rod ascends, the wire surrounding the polypus is carried up to 
the point of attachment. When well placed, the ends of the wire 
may be fitted to the ecraseur, and that instrument carried up to the 
ends of the rods. The ecraseur can then be manipulated until the 
tumor is separated. There is no need of removing the rods from the 
wire before the ecraseur is fixed, as their presence does not complicate 
the operation. 

All this explanation presupposes an open or dilatable condition of 
the os uteri which does not always exist. If the mouth of the uterus 
is not already thus patent, it should be dilated by compressed sponges 
until it will admit of free access. 

It requires much experience and tact to perform this operation 
with the ecraseur, and we will find in the books and periodicals a 
number of instruments intended to facilitate the application of the 
wire to the neck of the tumor. The dangers connected with this 
operation are those caused by the protracted efforts to replace the 
chain or wire of the ecraseur, and an inability always to remove the 
whole tumor. 

The operation of torsion can be performed when the tumor wholly 
or partly occupies the vagina without any preparation, and is prefer- 



660 



SUEGICAL TEEATMENT. 



Fig. 290 



able, because the tumor is removed at the point of attachment. The 
reason of this is, the point of attachment is always 
the weakest, and yields to the force applied before 
any violence occurs to the other parts of the tumor 
or the uterine tissue. The tumor is thus com- 
pletely removed, and without protracted manipu- 
lation. No hemorrhage results for two reasons : 1, 
there are no large vessels entering the tumor, and 
the small ones are torn instead of being cut as in 
amputation ; 2, septicaemia does not occur, for no 
portion of the tumor is left to slough. 

When the tumor is higher up, or within the 
cavity of the uterus, torsion is equally appropriate, 
and more easily executed than amputation with or 
without ligation. Of course if the mouth of the 
uterus is not open enough to permit the seizure of 
the potypus at a point high enough to secure a 
sufficiently firm hold upon it, dilation is just as 
necessary as in the other operations. The amount 
of dilation, however, will not need to be so great. 
In performing this operation, the operator must 
guide the forceps with his fingers to the part of the 
tumor necessary to enable him to fasten the instru- 
ment upon or near the central part of the polypus. 
In two instances where the tumor was too large to 
be firmly held by any forceps at my command, I 
introduced the hand inside the uterus and detached 
the tumors by rotating them with the hand, after- 
wards making traction with the forceps. I brought 
them into the vagina and delivered them with the 
obstetrical forceps. One of these weighed forty- 
six ounces. 

To perform torsion for the removal of a polypus, 
the surgeon, after fixing the instrument firmly in 
the desired position, should be careful to twist it 
enough to be sure of its detachment before com- 
mencing traction. Not less than from four to six 
complete revolutions should be effected. This pro- 
cedure will prevent the danger of lacerating the 
tissues of the uterus. 

The greatest objection urged against the opera- 
tion of torsion is the likelihood of lacerating the 
wall of the uterus at the point of attachment. If 
we will call to mind what was said about the rela- 
tive thickness of the muscular strata upon each 

side of the different kinds of fibrous tumors, we will at once perceive 



Chassaignac's fcraseur. 



REMOVAL OF POLYPOID TUMORS. 



661 



the groundlessness of this objection. In the pendulous variety the 
whole wall of the uterus is outside the point of attachment and is 
strong enough to resist the very few fibres that are carried down with 
it. Indeed, in the polypus there is almost no substantial attachment 



Fig. 291. 




Small Vulsellum Forceps. 



except that formed by the investing mucous membrane. If, therefore, 
the torsion is performed with sufficient thoroughness before traction 
is begun, laceration of more than the superficial tissues surrounding 



Fig. 292. 




Medium-sized Vulsellum Forceps. 



the neck of the tumor is next to impossible, and consequently the 
operation is perfectly safe. 

Hemorrhage is not so likely to occur after torsion as when the 
tumor is amputated by the knife, or scissors, or even by the ecraseur. 



Fig. 293. 




Large Vulsellum Forceps. 

The danger of hemorrhage, then, is an objection that cannot with any 
show of reason be urged against torsion. I have never seen hemor- 
rhage succeed torsion. The contractions of the uterus which take 
place after removing the polypous growth from the cavity of the 
uterus, in the great majority of cases, is as effective in the prevention 
of hemorrhage as it is when its contents are expelled at the time of 
labor. I trust that it is not necessary to dilate further upon this part 



662 SURGICAL TREATMENT. 

of the subject. However, let me remind the reader that as hemor- 
rhage, although improbable, is yet possible, we should be prepared for 
it. After what has been said under palliative treatment about the 
management of this complication, it will not be necessary to enlarge 
upon that point. 

After an operation of this kind the only treatment necessary is 
perfect quiet a few days, cleanliness by injections, and if needful 
the administration of anodynes to quiet pain. When a tumor has 
been removed from high up in the uterus the patient should of course 
be carefully watched, and if symptoms of inflammation or septicaemia 
arise they should be treated by suitable measures. 

Surgical operations having the relief of hemorrhage for their primary 
object, but which sometimes eventuate in the cure of the tumor, have 
been recommended and successfully practiced. 

The first I shall mention, is that brought into general notice by the 
late J. Baker Brown, viz., incising the cervix. 

Mr. Brown first discovered that free incision of the cervix would 
check hemorrhage by doing it as a preliminary step to coring or 
gouging out some of the tumor. He says, in tumors of recent origin 
and moderate size, free incision not only checks the hemorrhage, but 
often arrests the growth of the tumor, and even causes its disappear- 
ance. 

Of fourteen cases thus treated, in two only was it necessary to incise 
or gouge the tumor. 

When the vagina is small he first dilates it with bougies (some 
prefer sponge surrounded by thin india-rubber tubing). After the 
preparation of the vagina is satisfactorily accomplished, he exposes 
the cervix by introducing Sims's speculum, seizes, fixes, and incises it 
freely, its whole length from within outward, with Simpson's metro- 
tome, the incisions being made on both sides. He then plugs the 
cavity thus made with lint saturated with sweet-oil (if the oil was car- 
bolized it would be better), to prevent hemorrhage and to exclude 
air. Mr. Brown lays great stress upon a thorough plugging of the 
cervix after the operation, and filling the vagina with cotton to sup- 
port the cervical plug. He allows this to remain for forty-eight 
hours. He insists upon making the incision in the cervix to extend 
within the internal os uteri. The cavity produced in the cervix by 
the incision should be kept dilated until the surfaces cicatrize. If 
then the symptoms are not relieved, he proceeds to the operation of 
gouging out a piece of the most dependent part of the tumor. This 
may be done with a knife, but he prefers pointed scissors. 

The object of removing a part of the tumor is to inaugurate a de- 
structive inflammation, which will result in the disintegration and 
expulsion of the tumor. 

Sir J. Y. Simpson introduced the cautery or caustics into the sub- 



ENUCLEATION. 663 

stance of the tumor for the same purpose. In two instances I have 
caused fibrous tumors to disappear by passing cotton-wool into them. 
A large trocar was thrust through the cervical cavity as deep into 
the tumor as practicable, and after the stilet was withdrawn, several 
pieces of cotton secured by thread around them, were passed to the 
extremity of the canula into the tumor and held there by a probe, 
while the canula was also withdrawn. A discharge of fetid pus and 
serum followed moderate inflammation, and the tumor grew smaller 
until it disappeared. 

With my present experience, I would commend the administration 
of ergot, as soon as the tumor was affected by either of these opera- 
tions, with a view to aid in the expulsion of the growth. 

For the relief of excessive hemorrhage, Dr. Atlee passed a blunt- 
pointed bistoury into the cavity of the uterus, and by turning the edge 
of the instrument upon the tumor, cut deeply into it. The dilatation 
of the cervix, so generally indispensable, can be done by compressed 
sponge or sea-tangle tents, instead of incision. 

Enucleation. 

This term is applied to the operation of splitting the capsule and 
turning the tumor out of its bed. 

In favorable cases this operation is easily performed, but such 
cases are very rare ; generally it is one of the most formidable and 
dangerous operations that we are called upon to perform. I say this, 
with reference to the operation, when it is done by the most skilful 
and efficient gynecologist. In the hands of the reckless, uninstructed, 
and inexperienced, it is still more likely to be done badly, and indeed 
barbarously than any other operation. 

The operation of enucleation should be confined to submucous 
tumors, or, to speak more definitely, to tumors situated between the 
central stratum of muscular fibre and the mucous membrane. The 
intrusion of such tumors into the cavity of the uterus enables us to 
attack them from that cavity, and the thick, strong layer of muscular 
fibre lying outside of the tumor, makes the operation less dangerous 
by protecting the peritoneal cavity from the violence which might 
otherwise result from the most cautious use* of the instruments. 

When are we justified in making an attempt at enucleation? 

The first item in the answer to this question is, when it is evident 
that the patient's life will soon be sacrificed if the tumor is not in 
some way disposed of. The second item is, where every reasonable 
palliative measure has been tried without success, or where there is 
not time to wait for their trial, if such a condition can exist ; and I 
may add a third, where appropriate attempts have been made and 
failed to break them up and expel them with ergot. Some will object, 



664 SURGICAL TREATMENT. 

saying that ergot will not do this with any uniformity ; to which I 
would answer, that I do not believe the objectors have given it a 
thorough and intelligent trial. Some will further object, by saying, 
that the septic fever attendant upon such expulsion is more dangerous 
than the operation of enucleation ; to which I would answer, that my 
cases will not bear out the objection. I will also add, that the general- 
practitioner will conduct a case of expulsion more successfully than 
he can the operation of enucleation. 

The first step in enucleation is thorough dilatation of the cervix, if 
it is not already sufficiently open. The dilatation should be sufficient 
to permit the fingers to pass as far up into the cavity of the uterus by 
the side of the tumor as they can be made to reach. If the vagina is 
small, it should also be prepared by stretching or dilating it. 

When these conditions have been obtained, the patient should be 
placed upon her left side with her left hand behind her, and by Sims's 
speculum, the cervix and tumor exposed to view. The cervix should 
then be seized with vulsellum forceps, drawn down as much as possi- 
ble, and held firmly by an assistant until the operation is completed, 

Fig. 294. 




Sims's Enucleator. 



varying the direction of the traction as the operator may require. The 
capsule may then be opened by making an incision with long curved 
scissors, at the junction of the tumor with the wall of the uterus the 
whole width of the tumor ; at the middle of the incision another should 
be commenced, and carried as high up over the longitudinal centre of 
the tumor as possible. 

These incisions should not penetrate the tumor to any great depth. 
They should simply divide the capsule, and when the capsule is not 
adherent, the space between it and the tumor will be easily recognized. 
The fingers can then be inserted between the capsule and the tumor, 
thus separating them as Mgh as the operator can reach. This separa- 
tion should extend around the whole circumference of the growth. 

The fingers will not be long enough, usually, to reach over the upper 
end of the tumor; the separation may be completed by Sims's enucle- 
ator as seen in Fig. 294. It may be passed with the concave side next 
to the tumor, gently to the top, and then passed around in any direc- 
tion until the separation is complete. 

While this last part of the operation is being accomplished, another 
vulsellum should be fastened upon the tumor as high up as possible, 



ENUCLEATION. 665 

and by traction made to depress and steady it. When the tumor is 
thus separated from its capsule, we should make an effort to turn it 
upon its longitudinal axis. 

This will enable us to determine whether it is entirely detached or 
not, as well as to dislodge it from the muscular bed into which it has 
been moulded. If the detachment is not complete, the point of resist- 
ance will generally be discoverable by swaying it from one side to the 
other, or backward and forward, thus enabling us to apply the enucle- 
ator to the right place, and complete the separation. At this stage of 
the operation we may make more traction ; the dislodgment will be 
facilitated by pressure upon the fundus of the uterus by the hand of 
an assistant. When the tumor is not too large, it will descend as we 
pull upon it, and pass out through the vagina. If, however, it is so 
large that it cannot be made to pass through the vagina in this way, 
then the tumor should be split by the scissors from the bottom up- 
ward, as near the top as possible, without danger of wounding the fun- 

FlG. 295. 




Sims's Guarded Hook to aid in drawing the Tumor. 

dus of the uterus, and then (as Dr. Sims instructs us) one-half should 
be seized by the vulsellum and drawn down, so as to cause the tumor 
to undergo evolution ; the portion grasped coming down first, and by 
virtue of its attachment at the top, brings the other after it ; but if this 
cannot be done, we must cut off the part in the grasp of the vulsellum, 
seize another portion and treat it in the same manner, until the whole 
is removed by pieces. 

Under favorable circumstances this operation may be performed as 
above described; but obstacles will sometimes be met with that will 
give the best operators much trouble, and render the results very 
unsatisfactory. 

The first I will mention is that presented by imperfect capsulation, 
or adhesion of the tumor to the walls of the uterus. Some cases occur 
where the tumor is not isolated by a capsule from the uterine struc- 
tures, but the substance seems to be continuous with them. 

Whether this condition depends upon original formation, or is the 
result of disease, which causes adhesion between the surfaces of the 
tumor and the capsule, I am not able to say ; but in either case it 
presents an insurmountable obstacle to the perfect removal of the 
tumor ; and, if this condition could be diagnosed beforehand, it would 
contraindicate the operation for enucleation. 

When in the performance of the operation we meet with this ob- 



666 SURGICAL TREATMENT. 

stacle, and can clearly ascertain its existence, I think it would be best 
to gouge out as much of the tumor as we could safely remove, and 
then commence the administration of ergot, to remove the remainder. 
I would do this, because cutting through the superficial layer of the 
tumor would be sure to disturb its vitality. 

The next obstacle to the removal of the tumor by enucleation is. 
the great size to which it may attain. I have already spoken of the 
necessity of sometimes cutting the tumor in pieces with scissors to 
facilitate its removal. The wire 6craseur will often be very useful in 
lessening the size of the tumor. 

We slip the wire over a portion of the tumor and cut it off, then 
pull down more with the vulsellum, when that is possible, and pass 
the wire over another piece, and so on until it is small enough to 
remove. 

This plan, where practicable, and especially in the hands of the 
experienced operator, is the safest way. Dr, Thomas's serrated spoon, 
or a very small, crescent-shaped knife, such as is used by Dr. E. 
Warren Sawyer, of this city, may, by careful use, aid us in this 
respect. 

Hemorrhage constitutes a very formidable complication, in rare 
instances, in the operation of enucleation. I have never met with 

Fig. 296. 




6 ."WWC^Wtt & to 

Thomas's Serrated Spoon. 



this difficulty in the removal of these tumors by any method ; but 
there are too many cases on record to leave any doubt that we should 
be provided with the means of meeting hemorrhage of the most for- 
midable degree. 

In considering this matter in relation to the cases reported, I believe 
it to be the result of inertia, or want of firm contraction in the mus- 
cular fibre, or on account of the separation of a vessel in the uterine 
walls. In either case, if we continue the operation, we should follow 
the example of Dr. Emmet in throwing ice-water freely into the 
cavity of the uterus. I would also resort to obstetric doses of ergot ; 
both of them would serve to contract the vessels of the uterus, and 
overcome the inertia by prompting the uterine fibres to act. If, in 
spite of these remedies, the hemorrhage is so copious as to make 
delay very dangerous, we may inject the uterus with tincture of iodine; 
but I should greatly prefer immediate and complete plugging to any- 
thing else. If the hemorrhage has been sudden, shall we proceed 
with the operation? I think not, but would assign this to the cate- 
gory of cases which should be treated by ergot. 



i 



LAPAROTOMY. 667 

What has been said of enucleation has reference more particularly 
to deeply-seated submucous tumors which project into the cavity, but 
are imbedded their whole length in the wall of the uterus. The more 
superficial or sessile variety of submucous tumors project so far into 
the cavity as to appear to be implanted upon the wall beneath the 
mucous membrane of the uterus. The attachment, or base, upon 
which it sits, is nearly or quite the size of the tumor. This variety 
can be removed with much more facility. 

After exposing the tumor, and steadying it by traction with the vul- 
sellum, it may be separated from the wall, and that very neatly by the 
serrated spoon. This instrument should be inserted through the cap- 
sule, at the juncture between the tumor and the uterus, by a rotary 
sawing motion ; the growth severed by passing it through the capsule 
in any direction where the attachment exists. 

This is Dr. Thomas's method of removing this variety of tumors. 

Dr. Emmet pulls them steadily and persistently down into or toward 
the vagina ; this allows the upper portion of the uterus, from which 
the tumor is withdrawn, to contract. Further traction upon the tumor 
gives room for the fibres beneath the point of implication also to con- 
tract, until the circumference of the attachment, becoming smaller, 
assumes a pedunculated form, and may be severed by the ecraseur, 
scissors, or knife. This form of tumor may also be removed by pass- 
ing an ecraseur over and amputating a part of it, and then, by means 
of the finger or enucleator, remove the remainder. 

Patients who have undergone any of these operations for removal 
of fibrous tumors may die from shock, hemorrhage, inflammation, or 
septicaemia. 

For the treatment of shock, I will refer the reader to the subject as 
taught in the after-treatment of ovariotomy. 

I have already said sufficient upon the subject of treatment of 
hemorrhage as a complication in such cases. 

Inflammation, when it occurs, should be treated as in the after-treat- 
ment of ovariotomy. 

Septicaemia may be more effectually treated in connection with this 
than almost any other of the great operations, as we can keep the 
cavity clean by hot-water injections, and disinfected by carbolic acid. 
For the general treatment, I will refer the reader to the after-treatment 
of ovariotomy. 

Laparotomy 

For the extirpation of the tumor, is another surgical resource, of 
which we may avail ourselves under circumstances where the employ- 
ment of less hazardous measures is either impracticable or unavail- 
ing. 

The extirpation of the tumor, where it is subserous and pediculated, 



668 SURGICAL TREATMENT. 

has been performed a large number of times successfully ; and where 
the tumor is not adherent, there is no great difficulty in removing it in 
this way. 

The incision through the abdominal wall may be made in the same 
place and in the same way as for ovariotomy, although it will be 
evidently necessary to make it larger. 

The pedicle being exposed and ligated by a double silk ligature, it 
will be found that the substance through and around which the liga- 
ture is passed is not so firm as the pedicle of an ovarian tumor ; hence 
it will be necessary to be more careful, lest it give way and cause sec- 
ondary hemorrhage. 

The ligature should not be passed through any part of the tumor, 
but between it and the uterine substance ; then, to get sufficient sub- 
stance beyond the ligature, the capsule may be divided an inch from 
the ligature and the tumor enucleated. 

When the tumor is sessile, instead of being pediculatecl, and the 
base too broad to be included in a ligature or clamp after the abdomen 
has been opened, it may be enucleated by splitting the capsule and 
peeling it out with the fingers. I would suggest that when enucleation 
has been thus performed, an opening be made from the bed of the 
tumor into the uterus, so that the discharge from the empty capsule 
may find its way out through the uterus and vagina. 

To secure this evacuation, we might pass a drainage tube through 
the opening into the vagina. Where this or some other effective ar- 
rangement for drainage is made, the capsule may be closed by silk 
sutures, and the abdominal wound treated as for ovariotomy. If the 
capsule should not be large, and the operation has been performed, as 
it always should be performed, under the antiseptic conditions, it may 
not be necessary to make any provisions for drainage. 

When a subserous tumor is situated on the posterior wall, occupy- 
ing the cul-de-sac behind the uterus, it may be removed by making an 
incision along the median line of the posterior vaginal wall and re- 
moving the tumor through the vagina. Dr. R. S. Sutton, of Pittsburg, 
has successfully removed one in this way, as also has Dr. Clifton Wing, 
of Boston. 

Of course none but the small-sized tumors can be removed by this 
method. 

The thermo-cautery, or the actual cautery, should always be in 
readiness to stop hemorrhage in either of these operations. 

Lapa ro-hysterectomy. 

The last measure I will mention, as one resorted to for the relief of 
patients afflicted with these tumors, is laparo-hysterectomy, or the re- 
moval, partially or wholly, of the uterus with the tumor. 

This operation resembles in many respects that of ovariotomy. 



LAPARO-HYSTERECTOMY. 669 

Our preparation of the patient should be the same. The anaesthetic 
and the carbolic spray are used in the same way, as also in the anti- 
septic dressing. 

When we undertake the operation, we should be especially well 
prepared with means of arresting hemorrhage. To this end we should 
have in readiness the thermo-cautery, a number of haemostatic forceps, 
persulphate of iron, etc., and every other arrangement should be com- 
plete, so that there might be no delay, as the operation is almost of 
necessity one of long duration under the most favorable circumstances ; 
and it should be remembered that everything, which may shorten the 
duration of the operation is of great importance, as the longer it lasts, 
the more depressing its effects. For fear that what I may say should 
encourage precipitation, I would protest against hurry, and advise de- 
liberation in all the steps of the operation. 

The incision is made in the same place and manner as in ovari- 
otomy ; first a small incision, say four inches long, for exploration, to 
ascertain the character of the tumor, its probable adhesions, and its 
relation to the viscera. As some viscera, especially the intestine, is 
more frequent^ found to lie across the front part of the tumor, the 
necessity of ascertaining any such condition is much greater than in 
ovariotomy. 

When it comes to the separation of the adhesions and the removal 
of the tumor, the size of the incision must be increased sufficiently to 
permit the extraction of the whole mass, instead of an effort being 
made to lessen the size of the tumor, as in ovariotomy. 

An exception may be made to this teaching, if the tumor is not en- 
tirely solid, but of the fibro-cystic variety. In this case, if a large cyst 
presents itself, we may hold the tumor close to the incision with vul- 
sellum forceps and evacuate the fluid through a large trocar, or an 
incision into the wall of the cyst. If in doing this we find there are 
a number of cysts, we may introduce a finger, or even the whole hand, 
as I once did, into the centre of the tumor, and break it up as far as 
possible. In this way we may sometimes very greatly lessen the size 
of the tumor. 

In this operation, as in ovariotomy, the size of the incision is of 
great importance ; in no case should we risk bruising or tearing the 
abdominal walls. 

In operating for fibrous tumors, we should not trust to the sound 
in searching for adhesions ; the hand alone should be used, and the 
whole surface examined before any attempt is made to dislodge the 
tumor. 

We should also remember that the adhesions, as a rule, are more 
vascular than in ovarian tumor, and hence, when necessary, they 
should be ligated twice and cut between the ligatures. 

When solid, the tumor may be lifted from its bed more easily by 



670 SURGICAL TREATMENT. 

means of the vulsellum forceps than by the hands. After it is lifted 
out, the uterus will generally be found to be removed from the pelvis 
with the tumor constituting a part of the mass. 

If there are no more adhesions the junction between the tumor and 
uterus should be sought for. Sometimes the tumor is situated so low 
in the uterine walls that the appendages are carried high up, and 
may be considerably enlarged. It is then advisable to ligate the 
ovarian vessels laterally in the broad ligament, and the appendages 
near the uterus, and cut between the fimbriated extremity of the tube 
and the lateral ligatures. The peritoneal edges of the severed broad 
ligament may then be united. If the pedicle be thick, and the uterine 
vessels large, we may place a rubber tube tightly about the cervix, and 
tie the vessels above the tubing before the tumor is cut off. The 
bladder is usually in close proximity and must be carefully avoided. 

There are two methods of treating the pedicle, the extra-perito- 
neal and the intra-peritoneal. When treated extra-peritoneally the 
cervix or the uterine stump must either be inclosed in a clamp, con- 
stricted by rubber tubing, or ligated with heavy silk, before being cut 
off above, Spencer Wells was the first to treat the stump extra-peri- 
toneally. He transfixed it with two needles, ligated about them with 
a figure-of-eight ligature, and fastened it in the lower end of the wound. 
Pean deserves the credit of having developed this method. He passed 
two needles at right angles through the stump, and ligated it in halves 
under them by wires. If bleeding occurred afterward, the wires were 
tightened. 

On account of the liability of the wire to cut, and the ovarian 
vessels to slip out of the loop, Hegar* places a strong elastic ligature 
(rubber tubing) around the stump, cuts the tumor oif, sews the peri- 
toneal edges of the abdominal walls to the peritoneal covering of the 
stump below the elastic ligature, and transfixes the stump with two 
needles to hold it in place. 

The elder Keith, who has obtained the best results (35 recoveries 
out of 38 cases), fixes the pedicle in the abdominal wound with a 
clamp or wires. 

The after-treatment of the pedicle treated extra-peritoneally is usu- 
ally tedious, for the portion above, and sometimes that a little below, 
the clamps or elastic ligature sloughs out and leaves a large deep 
ulcer to be filled with granulations. The remaining stump under- 
goes considerable retraction, and draws the abdominal walls down 
toward the pelvic cavity. 

Schrceder,t who was the chief representative of the intra-peritoneal 
method, placed a rubber ligature around the uterus and appendages 

* Operative Gynakologie. Hegar and Kaltenbach. 
f Op. cit. 



LAPAROHYSTERECTOMY. 671 

below the tumor, and cut the latter off at its junction with the uterus 
as a piece is cut out of a melon (wedge-shaped). He then trimmed 
the stump, if necessary, till the peritoneal edges could be made to 
cover it, and disinfected the exposed cervical or uterine cavity with a 
ten per cent, solution of carbolic acid or the thermo-cautery. Having 
done this he sewed up the uterine cavity, and then the raw surfaces 
of the stump, with several rows of stitches, beginning at the bottom 
and culminating at the top with a fine row uniting the peritoneal 
edges. He used catgut for the uterine cavity and peritoneal edges, 
and silk for the rows of stitches uniting the raw surfaces where there 
was apt to be considerable strain upon them. 

Dr. Charles T. Parkes, of this city, ligates the stump with silk, 
thoroughly sears it with the thermo-cautery and drops it. He reports 
six cases : with two recoveries treated in this way, and four deaths 
with the stump treated extra-peritoneally. 

Among 135 cases Schrceder lost thirty per cent. This percentage 
in the cases of so skilful an operator would indicate that the dangers 
of his method are great, or that it was but imperfectly developed. 
The statistics of the recorded extra-peritoneal operations are far better, 
although the recovery is usually more tedious. There is much reason 
to believe that Parkes's method approaches more nearly to the ideal 
than any of the others. 

Woelfler and Hacker* stitch the stump (united according to Schrce- 
der's precepts) into the wound, so that it is extra-peritoneal but under 
the abdominal parietes. 

The difficulties in the intra-peritoneal method are, that if the stump 
is not tied tight enough hemorrhage will result, if tied too tight or too 
extensively sloughing may occur. 

" Dr. Le'on Labbe' communicated, at a late meeting of the Academie de Medicine, a 
note relative to a modification of the operation of hysterectomy as applied to fibrous 
tumors (exsanguinification of the tumor). 

" Gastrotomy applied to the treatment of fibrous tumors of the uterus is an opera- 
tion about which there is no longer any dispute. The note which M. Labb& com- 
municated to the Academy is not for the purpose of describing this operation,, but 
simply to make known aa important modification that he has introduced in the opera- 
tive process. 

"The quantity of blood contained in these enormous uterine tumors is. always con- 
siderable; it is certain that the loss of this blood by the ablation of the tumor is a 
factor, the importance of which cannot be passed over, especially if we consider that 
the extirpation of these tumors almost always takes place in the cases of women who 
are in an advanced state of cachexia. Based upon the principle which had led Es- 
march to apply a compress bandage on limbs which were to be amputated, M. Labbe* 
thought the same bandage could be utilized to press back into the general circulation 
the blood contained in large uterine tumors, and thus practice a kind of transfusion... 

" The patient for whom he had occasion to apply this principle for the first time,. 

* Schrceder, op. cit. 



672 SUEGICAL TREATMENT. 

was in a deplorable condition before the operation, and succumbed six days later to 
septicemia ; but M. Labbe' has been able to prove that the enormous fibroma upon 
which compression was first practiced was entirely exsanguined, and that about a litre 
of blood was by this means restored to his patient. 

" The theory which led M. Labbe to apply Esmarch's compress to restore to the 
geueral circulation, at the time of their extirpation, the blood contained in such great 
abundance in the fibro-myomas of the uterus, is very clearly justified by the case which 
has been reported to the Academy. 

11 The peculiar conformation of the tumor was such that no very particular method 
was employed in this case ; but if the tumor to be operated on is more regular in form 
we would have just reason to fear that the application of the elastic band might present 
some difficulties. In this case, to fasten the band and give it a support we should 
transfix the tumor near its summit by one or more metallic needles. Several of these 
needles may even be placed at different heights so as to give support to the compress, 
and to prevent its slipping. 

"M. Labb6 concludes : 

"1st. That there must be a positive advantage, in operations on large uterine fibro- 
myomas removed by gastrotomy, in restoring to the patient the blood which these 
tumors always contain in large quantity. 

"2d. That this result may be employed in a complete manner by applying to the 
tumor Esmarch's compress, or any other compress endowed with the same elastic 
properties."— Gazette Hebdomadaire, 6 Aout, 1880; American Journal Medical Sciences, 
October, 1880. 

"When the ligature is satisfactorily applied we must remember also 
that in cutting away the tumor there is great danger of retraction of 
the parts included in it. The abdomen must be carefully cleansed 
and hemorrhage entirely checked before closing the wound. 

The after-treatment of these cases is more difficult than in ovari- 
otomy, as the shock is ordinarily much greater, and inflammation and 
septicaemia more likely to follow the operation. 

I do not believe the complete extirpation of the uterus and ovaries 
will bear any reasonable comparison with ovariotomy, even double 
ovariotomy. 

In comparing these operations we must remember that when the 
uterus and both ovaries are removed, the whole genital system, with 
all the reflex capacities and sympathetic relations, is suddenly torn 
from its connections. The centric connections supplied to these organs 
by a complete system of nerves ; the moral, emotional, and physical 
energies they are continually exerting over the whole of the rest of 
the organism are destroyed. The importance of the relations between 
the genital system of woman and the rest of her body and brain is so 
great that it can scarcely be appreciated. These relations constitute 
the major part of her life. 

From such considerations, I can but believe that the shock of this 
operation is incomparably greater than in ovariotomy or double 
oophorectomy. 

When one ovary is removed, the other maintains the ovarian in- 



OOPHORECTOMY. 673 

fluence over the uterus and the system at large. When both are re- 
moved, there is still left the larger part of the genital nervous system, 
with its relations, although impaired, not entirely severed ; and we 
know, from observation, that in such cases womanhood is well pre- 
served. 

In operations of this kind, conservative surgery is of the greatest 
importance, and we ought never to remove the ovaries when we can 
preserve them. 

While there will continually occur cases for which this operation is 
the only remedy, experience will prove it to be an operation of much 
more gravity than ovariotomy in any of its forms. 

Kimball, Burnham, H. R. Storer, Thomas, and other Americans 
have performed this operation successfully. 

In Europe, Pean, Koeberle, Wells, Clay, Schroeder, and others have 
contributed toward perfecting hysterectomy for fibrous tumors. 

Oophorectomy — Battey's Operation — Spaying. 

These are terms intended to designate an operation for the removal 
of the ovaries. 

To Dr. Robert Battey, of Rome, Georgia, is due the credit of first 
removing the ovaries for the purpose of artificially inducing the 
menopause. 

The knowledge that the change of life generally brings relief from 
the intolerable and irremediable forms of oophoro-neuroses that so 
often perplex the practitioner, would lead to the hope that the re- 
moval of these bodies would produce similar cures. This operation 
has been before the professional public for about eleven years, and the 
mortality which was at first above twenty per cent, has now fallen 
below ten per cent. Dr. Paul F. Munde {American Journal of Obstetrics) 
very correctly observes that if the positive benefits of the operation 
were as assured as the favorable rate of mortality, the opposition to 
it would soon cease. The operation has also been repeatedly per- 
formed for the purpose of arresting the growth of fibrous tumors of 
the uterus, on account of the favorable effect the natural menopause 
so generally produces upon them, and in some instances with very 
favorable results. 

We should not forget, however, that menopause is not the change 
of life. 

This condition — menopause — is sometimes brought about by some 
of the very conditions for which Battey's operation is performed with- 
out producing change of life. 

It is true that the ovary, if not the essential agent, is certainly 
necessary to the proper development of the female genital organs. 
After the genital apparatus is mature, it is probably the fountain of 

43 



674 SURGICAL TREATMENT. 

the excito-motor influence upon which depend the functions of the 
uterus and its appendages in all their relations to the generative acts. 
The ovaries ought not, therefore, to be classed as appendages to the 
uterus ; rather the latter is, in the proper sense, an appendage to the 
former. 

As an accompaniment of ovulation, which is the development and 
disengagement of the ovule, the trophic energies of the uterus are ex- 
cited in corresponding degree. 

The repletion and activity of its circulatory system corresponds to 
like changes transpiring in the ovaries, and the nervous system of the 
uterus is acted upon by that of the ovaries, prompting glandular 
changes in the mucous membrane. 

Even the intramenstrual growth and hypertrophy of fibrous and 
other tissues of the uterus are but the reflex complement of the stromal 
hypertrophy of the ovaries. As the ovarian excito-motor stimulation 
is withdrawn from the uterus, involution simultaneously occurs in the 
two. It is true that the removal of the ovaries withdraws the source 
of the excito-motor influence from the uterus, and this generally 
brings about the menopause in the sense of the cessation of periodical 
hemorrhages; but the same operation, after the uterus has obtained 
maturity of organization, and especially when its tissues have become 
hypertrophied (vascular, nervous, and muscular), leaves a large, highly 
organized organ without its regulating apparatus, the subject of any 
morbific cause which in its nature has any aptitude for the production 
of uterine derangement. 

"We see this illustrated in the case given by Dr. Trenholme, the 
history of which, subsequent to the operation, I give below. 

This, I think, is the effect produced by suddenly removing the ova- 
ries in large fibrous tumors of the uterus. In smaller growths, and a 
less vascular state of the uterus, the same conditions exist, and the 
same consequences will follow, only in a less noticeable degree. 

The senile menopause, one of the symptoms of the change of life, is 
the consequence of gradual changes in all of the organs concerned. 
This change is a degeneration of the genital organs. 

The tissues are not merely diminished in size, but they degenerate 
into those of a lower order of organization, and this same degeneration 
extends itself to the morbid growths of the organs. 

Tumors lose their vascularity, their fibres disappear, and the whole 
becomes a degenerate mass. 

It is not certain how much of this general and regular degeneration 
is due to the presence of the ovaries and their excito-motor energies in 
prompting it and in governing its nature. 

It is a plausible supposition, however, that as the ovarian changes 
and influences are so great in building up the uterus and sustaining 



OOPHORECTOMY. 675 

its functions, it might be as efficient in its retrograde transformation, 
thus making it more complete. 

The removal of the ovaries in the presence of a large fibroid and 
hypertrophied uterus, simply takes away their governing agency 
before the process of degeneration has begun. We have then a highly- 
organized uterus and tumor, and if degeneration takes place at all, — 
which I very much doubt, — it is not normal in any respect, and may 
be the cause of morbid instead of salutary conditions. 

We then exchange one evil for another ; a greater for a lesser it may 
be ; to the advantage of the patient somewhat, but yet not so as to 
make a perfect cure. 

Dr. E. H. Trenholme, of Montreal, reports a case* of abdominal 
oophorectomy for a large fibrous growth of the uterus in January, 
1876. Severe uterine pains and hemorrhage were the actuating reasons 
for the operation. The patient, according to her own account, was 
very much improved for four months succeeding the operation, the 
uterus then (in May, 1876) suddenly commenced enlarging and gave 
her very great pain. The enlargement and pain were accompanied 
by copious hemorrhage. As the result of this attack, she was confined 
to her bed more or less constantly for three months. Recovering from 
this attack she was able to support herself a part of the time as a sales- 
woman, and a part of the time as a nurse, for several months. 

In December, 1877, she had a similar attack and of like duration. 
The patient has now been in this city about two years, and I have 
had the opportunity of seeing her in two or three of these attacks. 
The pain is exceedingly severe and requires the use of anodynes in 
considerable doses to relieve it. In April, 1878, one of these attacks 
commenced and kept her in bed for several weeks. And in December, 
1879, another similar attack prostrated her, with pain and hemorrhage, 
lasting until the middle of March, 1880. 

During the whole continuance of this attack she was in the Woman's 
Hospital, of the State of Illinois, under my immediate supervision. 
During the early part of this last paroxysm, the uterus was enlarged 
until it extended two inches or more above the umbilicus, and occu- 
pied all of the central and lower portion of the abdomen to within two 
inches of the crest of the iliac bones on either side. 

Since the subsidence of the symptoms, the uterus and tumor have 
decreased about one-fourth. 

The tumor is now somewhat elastic, whereas during the early part 
of the paroxysm it was very firm. 

The health of the patient is so very poor and uncertain, and she so 
dreads the suffering she experiences during the attack, that she now 
begs the removal of the entire mass. She is an intelligent woman, 

* Obstetric Journal of Great Britain, October, 1876, p. 430. 



676 SUKGICAL TREATMENT. 

and has made herself quite conversant with her condition and the 
extreme measures sometimes resorted to for relief, and is entirely will- 
ing to abide the consequences of the operation. 

I am deterred from indulging her wish for the removal of the tumor 
by hysterectomy, by the apparent general and very firm adhesions 
of the front surface of the tumor to the anterior walls of the abdomen. 

Whether this patient's life has been prolonged by oophorectomy or 
not, of course no one can know. That her condition, so far as suffer- 
ing is concerned, has been greatly improved, I think any one witness- 
ing her agony and prostration during a paroxysm would believe. And 
while I have no doubt of the thoroughness and skill of the operation, 
I must say I believe it to be a partial failure. 

In presenting these reflections on the difference between the effect 
of a natural change of life and oophorectomy upon fibrous tumors of the 
uterus, I do not wish to be understood as opposing oophorectomy. 
They, however, make me hesitate to give an unconditional adhesion 
to the practice, even where in our present knowledge it would seem 
indicated. 

The effect of removing the ovaries for intolerable and incurable 
cases of oophoro-neuroses, is quite another thing ; for then we remove 
the cause of the disease, or rather the symptoms ; because, as they are 
the organic origin of the neuroses, their condition is the disease, and 
like amputating a limb, that is incurably diseased, to get rid of the 
symptoms, we cut off the ovaries for the same purpose. 

There is another side to this subject, however, and that is, the general 
condition of the patients, who are the subjects of these nervous symp- 
toms, in such as, in part, to account for their suffering. And we 
sometimes find that a radical change in the circumstances under which 
they live, will dispel their trouble. Instances of this kind must have 
fallen under the observation of most practitioners of long experience. 
Muscular labor, outdoor exercise, and the loss of luxuries, when brought 
by inexorable bad fortune, have done wonders, in the way of remov- 
ing oophoro-neuroses. 

Then the question comes up, whether we ought to spay our patient 
or prescribe and enforce the proper amount and kind of primitive 
living necessary to revolutionize her nervous functions. 

The former course is the easiest, and, I am sorry to say, most accept- 
able to some patients. 

The following are Dr. Battey's* conclusions as to the proper cases 
for oophorectomy : 



* "What is the Field for Battey's Operation ?" A paper read before the American 
Gynecological Society in Cincinnati, September 1st, 1880, by Dr. Robert Battey, of 
Rome, Georgia. 



OOPHORECTOMY. 677 

"It is not a question as to whether extirpation of the ovaries shall be resorted to, or 
whether valerian or asafoetida be given, or resort be had to any other known resources 
of gynecology, but the case must be narrowed down to this, as the only expedient 
available." 

The following are the classes in which he regarded the operation as 
justifiable : 

" 1st. Congenital absence of the uterus, coupled with ovulation, in which, at the men- 
strual epochs, there are violent vascular and nervous perturbations, that are either 
dangerous to life or destructive to the health and happiness of the patient. 2d. Com- 
plete occlusion of the utero-vaginal canal. 3d. Certain cases of menstruo-mania, abso- 
lutely incurable by any of the known resources of medical science or art. 4th. Ovarian 
epilepsy. 5th. Certain cases of chronic ovaritis. 6th. Certain cases of amenorrhoea. 
7th. Ovarian hernia. 8th. Submucous or interstitial fibroids. 9th. Incurable flexion 
of the uterus. 10th. Csesarean section." 

This last, of course, means cases in which patients cannot be deliv- 
ered per vias naturalis. 

In deciding whether or not he should advise the operation, he asks 
himself three questions : 

"1st. Is this a grave case? 2d. Is it a case incurable by any other known resources 
of medical and surgical art? 3d. Is it curable by the menopause ?" 

If all are satisfactorily answered in the affirmative, he regarded the 
case as a proper one for the operation known as Battey's. If either 
question cannot be answered satisfactorily, he regarded the case as 
one in which the operation is not justifiable.* 

While these positions are not all as definitely put as they ought to 
be in a matter of so great importance, one thing is made plain by 
them, and that is, Dr. Battey regards the operation as a last resort. 

We are not yet able to do more than practice Battey's operation 
according to the imperfect light we have upon the subject, because it 
is the only available means of relief we can command. By intelli- 
gently watching effects we will be able after awhile to arrive at defi- 
niteness of indications for its employment. Too much latitude is 
given by some and too little by others, and it will require much 
more observation before all shall agree upon the question — when 
shall we resort to this operation ? The final position of the profes- 
sion must come as the result of an earnest and sober estimate of col- 
lected facts ; sentiment should play no part in the matter. The 
attempt to settle this question by facetious reveries as to the value 
of the ovaries and supercilious flings at gynecologists, has become 
monotonous and contemptible. Until sufficient knowledge, derived 
from careful observation, is obtained to guide the practitioner defi- 

* American Journal of Obstetrics, October No., 1880. 



678 SURGICAL TREATMENT. 

nitely to unimpeachable conclusions, we must do as the members of 
the profession have heretofore always been obliged to do — be governed 
by what light we have. If we do this honestly we will be in the line 
of our plain duty. 

There are some indications for oophorectomy upon which well- 
informed gynecologists agree : 1st. The absence or rudimentary 
development of the uterus, with such severe dysmenorrhoeal symp- 
toms as greatly to impair the health and usefulness of the patient. 
2d. Demonstrable structural lesions of the ovaries, with s}^mptoms of 
such gravity as to entail hopeless invalidism upon the subject of 
them. 3d. Incorrigible displacements of the ovaries, with invalidism. 
4th. The presence of a solid or cavernous fibrous tumor of the uterus, 
attended with uncontrollable hemorrhage, or causing dangerous pres- 
sure. 

Most other indications are subjects of discussion ; while some of 
them are sufficient to induce some men to operate, others would hesi- 
tate, if they did not reject them as insufficient. Such are oophoro- 
mania, oophor-epilepsy and oophoralgia, nymphomania, and perhaps 
others. These names are according to Battey, and doubtless correct. 
The presence of any of the symptoms enumerated in this last series 
of indications is only conditionally a reason for operation. If the 
symptoms can be traced to ovarian irritation, cannot be cured by any 
other mode of treatment, and are sufficiently severe to disqualify the 
patient for the enjoyment of happiness and the discharge of useful 
duties, the indication is clearly made out. It is but fair to admit that 
there may be, and probably are, cases of mania and epilepsy of the 
type of description contemplated in this connection, that do not de- 
pend upon ovarian irritation. And no doubt there are cases which 
have their origin primarily in ovarian irritation and are perpetuated 
after this cause is removed, by centric conditions resulting from the 
powerful and frequently repeated reflex impressions to which the ner- 
vous centres have been subjected. These admissions, however, cannot 
exclude ovarian irritation as a frequent cause of oophoro-mania and 
epilepsy. 

Is there any essential difference between the epileptic and maniacal 
seizures caused by ovarian irritation, and those arising from other 
causes ? I am not disposed to answer this question, but would sug- 
gest that so far as the brain is concerned, the condition is probably 
the same as it is in other forms of reflex mania or epilepsy. In the 
one case the aura arises in the ovary, and in the other some other 
diseased point. 

Operation. 

The operation as a laparotomy is in the main features similar to 
abdominal section for other purposes. It may not be unprofitable, 
however, to pass the different steps of the operation in review. 



OOPHORECTOMY. 679 

The preparation of the patient's room and other surroundings 
should be as thoroughly antiseptic as possible, and the strictest pre- 
cautions taken to avoid all risks of septic exposure from every source. 
The bowels should be well evacuated ten or twelve hours before the 
operation ; as when there is much fecal matter or gas in them the 
intestines will be very much in the way and prove a source of much 
embarrassment to the operator. To still further secure an empty con- 
dition of the alimentary canal the patient should entirely abstain from 
eating the meal before the operation. The bladder should be thor- 
oughly evacuated only a few minutes before the anaesthetic is given. 

The incision is made in the linea alba, commencing about an inch 
above the pubis and extending upwards two inches if there is not too 
thick a layer of adipose tissue. If the fat is two inches or more in 
depth, it may be lengthened accordingly. The strokes of the knife 
may be free until the skin and fat are divided down to the fascia cov- 
ering the tendon uniting the flat muscles of the abdomen. When this 
is fairly exposed it will be better for the inexperienced operator to 
cautiously lift up thin layers of the presenting tissues and divide them 
with a blunt-pointed bistoury or scissors until another adipose layer 
is reached. This fat is in contact with the peritoneum and clearly 
indicates our near approach to that membrane. Before proceeding 
further all hemorrhage should be arrested. When this is done we 
may lift the fat between the thumb and finger sufficiently to raise it 
and the peritoneum, to which it adheres, clear of the abdominal con- 
tents and make an opening in them through which a grooved director 
or the finger may be passed, upon which to enlarge the opening to the 
size of the external incision. Looking into the abdomen we will gen- 
erally see the omentum covering the intestines, whose convolutions 
will be plainly visible through it. Sometimes the omentum does not 
extend so low, and then the uncovered intestines will be exposed to 
view. Freshly cleaning our hands we pass the two fingers of one 
hand through the incision down into the pelvis — over and not through 
the omentum — in search of the uterus, from the fundus of which we 
can easily trace the Fallopian tube and ovarian ligament to the ovary. 
When there are no morbid adhesions the ovary and tube may be 
raised to the opening in the abdominal walls and exposed to view. 
They should both be drawn up so that a double ligature can be passed 
beneath them and tied over either side. As much of the tube should 
be drawn into the ligature as we can include without forcibly stretching 
it. In cutting through the pedicle thus made we should be careful to 
remove all the ovarian stroma. This precaution is necessary because 
the presence of a small part of this substance may perpetuate the evils 
for which the operation is performed. It is not sufficient to place the 
ligature around the ligament and vessels of the ovaries. This, it would 
seem, does not prevent ovulation. Great care should be taken to 



SURGICAL TREATMENT. 

ligate the pedicle bo as tc gi ve rooni for the complete excision of the 
ovary and vet leave sufficient substance to avoid the danger of the 
ligature slipping off. In some cases, after the incision is completed. 
the operator will be met by adhesions of the omentum to the bladder 
and intestines, or by the adhesion of the convolutions of the latter to 
each other, to the bladder, or other organs, in such a way as to bar the 
entrance to the cavity of the pelvis. This will require careful, gentle. 
and patient effort- at -: ration. These attempts should be made at 
the sides of the pelvis, in the neighborhood of the ovaries, and to such 
an extent only as is necessary to reach these organs first on one side 
and then the other. Wh ether this kind of obstacle exists or not. the 
ovary and tube may be involved in a mass of exudation which almost 
invests them. In the wors: forms of such involvement, whether it is 
not better to abandon the attempt to remove, is a question of great 
importance, to be decided by the circumstances as met with in each 
'. ? -: -. If we decide b ire generally will, to proceed we should depend 
upon stretching as much as possible. Sometimes gentle and perse- 
vering traction between the thumb and finger will lift them out of the 
mass sufficiently to pass a ligature beneath them. We may greatly 
facilitate access to the ovaries by having an assistant press the wall 
down well in the side we operate upon, not merely to draw the side 
of the incisior_ so as to open the wound, but to depress the margin of 
it into the pelvis toward the ovary. If it becomes necessary to tear 
these organs loose, the violence should be over as small an area as pos- 
sible, and measm as :aken to stop hemorrhage if any occurs. See 
surface-ligation as shown in connection with Ovariotomy. The length 
of the incision in cases of great adhesion should be increased, and 
when we operate for the removal of the ovaries and tubes in the pres- 
ence of a fibroid tumor of the uterus, the incision should be longer 
than in other cases. The ovaries are sometimes lifted high above the 
pelvis by the tumor and may be found on the side of, behii: 
before it. Less frequently they are found near their normal position. 
In ordinary cases the incision should be small and not large enough 
to admit the hand. Where there is plenty of room to do so, the hand 

ry apt to find its way into the abdominal cavity, a practice that 
ought to be avoided as much as possible. The most important items 
in this operation are gentleness and avoidance of all unnecessary ma- 
nipulation. A looker-on can give a [ retty good prognosis by observing 
_ nd amount of manipulation practice:! by the operator. 
The after-treatment is bo like ordinary ovariotomy that it is only 

«ai y to refer the reader to that subject. 

Ph need and Psychical Results. 

I have four patients from whom I have removed both ovaries, 
whom I occasionally meet, and bo far as I can see^ and from explicit 



OOPHORECTOMY. 681 

assurances given by them, I believe they are not unsexed in any 
other sense than that they are sterile, and do not menstruate. In 
morals, manners, appearances, affections, propensities, and voice, they 
remain the same. 

The operation of removing the ovaries per vaginam was first per- 
formed by Dr. Battey. After exploring the posterior and vaginal 
walls Dr. Battey made an incision in the central line, about one inch 
and a half long, and with his finger drew the ovaries through the 
opening, ligated them and cut them off. 

Since then the operation has been repeated in the same way by 
others. The ovaries have also been removed a number of times 
through the abdominal walls. The main obstacle to be met in the 
performance of the operation is the adhesions arising from previous 
or existing inflammation. Sometimes this obstacle is so great that 
the operation through the vaginal wall is extremely difficult, and 
occasionally quite impossible. In such cases laparo-oophorectomy 
would be the easiest operation. 

The incision in this operation should be made in the same place as 
for ovariotomy, and no larger than is necessary. Tait sometimes 
removes the ovaries through an opening an inch long, but probably 
two inches will be a more frequent incision. 



CHAPTER XLI. 

AFFECTIONS OF THE OV ABIES. 

Conger, ital Atrophy. 

The ovaries, like the rest of trie genital organs of woman, may be 
imperfectly developed. It is not unusual to meet with a woman whose 
sexual system is developed only to a degree usually found to indicate 
the completion of childhood. The breasts are about the size and shape 
of the girl at twelve years of age. She does not menstruate, and per- 
haps is not endowed with the sexual desires common to the sex ; and 
if married, fails to bear children. The uterus, if examined, is found 
small, as are also the clitoris, labia and nympha. In all the instances 
of this kind that have come under my observation, the individuals 
were otherwise well developed. Xot unfrequently, however, as shown 
by other observers, the whole person is deficient, never attaining to 
more than the stature of a child. Cases of the congenital atrophy of 
the ovaries are given in this work under the head of amenorrhcea, 
with the method of treating the condition. Senile atrophy of the 
ovaries needs no description in this place. 

Hypertrophy. 

Enlargement of the ovaries is probably occasionally due to an in- 
crease in size without other alteration of their tissues. This is hyper- 
trophy. It is supposed to result from prolonged congestion, causing 
hypernutrition of the organ. The disease is hypothetical, as it has 
not been demonstrated. 

More frequently the enlargement is caused by an increase of some 
of the natural tissues and by inflammatory effusions. This last enlarge- 
ment is, of course, due to chronic inflammations. It is not easy, if at 
all practicable, to diagnosticate hypertrophy of the ovaries. We can 
generally detect enlargement of these bodies by physical examination, 
but cannot in all cases determine with certainty the nature of the 
enlargement. 

Displacement. 

Their intimate and firm ligamentous connection with the fundus 
of the uterus causes them to partake of the changes in the position of 
that part of the organ. Thus, when the fundus rises into the ab- 
dominal cavity during pregnancy, the ovaries are carried up with it, 



DISPLACEMENT. 683 

and in very thin persons they may sometimes be felt as small, mov- 
able, sensitive tumors upon the side of the uterus (see pp. 69-72). 

The same thing occurs in some cases when the uterus is much 
enlarged by a fibroid tumor. In the former condition the displace- 
ment is physiological, and does not ordinarily give rise to serious 
inconvenience, unless the organ is rendered unusually sensitive by 
disease. When the uterus is retroverted or retroflexed, the ovaries 
are displaced to a greater or less extent downward and backward, and 
sometimes this displacement is so great that they may be felt in the 
posterior cul-de-sac and constitute a very annoying complication. In 
fact, this condition is of more consequence than the uterine displace- 
ment, and is a serious barrier to the correction of the malposition of 
the uterus, on account of their liability to be compressed by the in- 
strument used to hold the uterus in place. But sometimes the ovaries 
fall into this position without the uterine deviation. When this is 
the case there are likely to be many grave symptoms, which are 
included in the vague and imperfectly understood term "ovarian 
irritation." In most cases of this nature the ovaries are the subject 
of some form of organic disease, and we may reasonably doubt 
whether the symptoms do not arise from the pre-existing disease rather 
than from the deviation from their normal position. There can be 
no doubt, however, that the displacement may greatly embarrass the 
circulation in them, and thus contribute still farther to their morbid 
condition. In such cases, the extensive reflex nervous influence 
exerted through the genito-spinal centres awakens a long chain of 
morbid phenomena destructive of the comfort of the patient, and 
sometimes establishes a series of oophoro-neuroses that wrecks the 
patient mentally and physically. 

Finally, I may say that rarely these organs may make their way 
out through the inguinal canal, in something of the same way that 
the testes do in the male. As there is no scrotum, however, in which 
they can find lodgment, they are arrested at the upper border of the 
pubis, and there constitute a harassing and painful hernia. This 
ovarian hernia may generally be diagnosed from the omental or in- 
testinal hernia, from the facts, first, that these two latter seldom pass 
out through the inguinal ring in the female, though frequently through 
the femoral ring; second, that they are not particularly sensitive to 
the touch unless in a state of inflammation from strangulation, while 
the ovary is quite sensitive ; and, third, that the sensitiveness of the 
ovary is said to be peculiar, resembling nothing so much as the sick- 
ening sensation experienced upon pressing the testicle, while the 
sensation of omental or intestinal hernia is rather the tenderness of 
inflammation. 

Having referred to the different varieties of ovarian displacements, 
I desire now to confine myself to the pelvic deviations of position. 



684 AFFECTIONS OF THE OVARIES. 

Symptoms. 

What are the symptoms of pelvic displacements of the ovaries? 
Having already referred to them, I shall be brief in their further con- 
sideration. 

They may be included under two heads, local and general. The 
local symptoms are not distinctive. They are pain, weight, or bear- 
ing-down sensation, sometimes heat in the pelvis, backache, sacral 
and coccygeal tenderness, and occasionally radiating neuralgia ; there 
are also very frequently, though not always, menstrual derangements, 
but these local symptoms may be produced by many of the disorders 
incident to most of the pelvic organs. 

As to the general symptoms. They are quite numerous and varied. 
It is indeed questionable whether all of the hystero-neuroses should 
not be regarded as oophoro-neuroses ; that is, direct or indirect morbid 
emanations from the ovaries themselves. It is probably impossible 
for us to separate the general symptoms arising from disease of the 
pelvic viscera into uterine, ovarian, vaginal, and vulval, as the nerve- 
supply to these organs is essentially a unit, and for their nervous 
manifestations are subject to the same presiding centre. 

In them is comprised a circle of functions to the perfection ot 
which, soundness in all of the organs is essential. Whether the ter- 
rible nervous symptoms arising from certain diseases of the vulva, the 
vagina, or the uterus can be reflected upon the organization in any 
other way than through their connection with the ovaries is a ques- 
tion not yet solved. I think we cannot doubt, however, that to 
"ovarian irritation" may be attributed the whole array of reflex phe- 
nomena so frequently noticed in the wrecked condition of broken- 
down women. 

In the retrouterine displacements of the ovaries, these conditions 
are prominent features, the numerous symptoms often assuming a 
very aggravated form, and the suffering of the patient becoming un- 
endurable. The general symptoms are those of ovarian irritation, 
and this is to be expected, because the circulation and the innerva- 
tion of these organs must necessarily be very much interfered with by 
their malposition. 

The Diagnosis 

Of these displacements is not generally very difficult. When in the 
inguinal canal, an examination of the tumor, its shape and peculiar 
sensitiveness are both characteristic ; the only thing for which it may 
be mistaken is hernia of the omentum or intestine, and a tumor 
formed by the protrusion of either of these is more globular, less firm, 
and unless in a state of inflammation is not very sensitive. When 
in the cul-de-sac behind the uterus if not changed in shape by disease 
the ovary has the same outline as when naturally situated and is 



CAUSES — EFFECTS PROGNOSIS — TREATMENT. 685 

movable. We may reach it by passing one or two fingers deep into 
the vagina or rectum. 

Causes. 

In many instances this displacement is associated with retroversion 
or retroflexion of the uterus, and is apparently the result of the mal- 
position of that organ. In others, however, the ovaries fall behind 
the uterus, because of their enlargement and increased weight from 
structural disease. Possibly a relaxed condition of the fold in the 
broad ligament in which it is contained, may permit the ovary to 
settle down out of its natural position. 

Effects. 

Are displacements of the ovaries always and necessarily accom- 
panied by serious local symptoms or destructive general disturb- 
ances? I think not. Probably every gynecologist of extensive ob- 
servation has noticed instances in which the ovaries could be felt in 
the cul-de-sac, and the patient experience little if any inconvenience, 
from such malposition. These, judging from my own observation, 
are not very uncommon cases. 

Why should some patients suffer so much from these displacements 
while others experience so little inconvenience from them ? 

In answering this, I must employ a term that is not very definite, 
and perhaps not always intelligible, " nervous susceptibility." This 
nervous susceptibility with some patients appears to be a part of their 
original construction or " make up " if you please, while with others 
it is an acquired condition. 

Nervous susceptibility and neurasthenia, if not connected as cause 
and effect, are at least very intimately associated, and to treat, these 
cases successfully therefore, we must have in mind this item of ner- 
vous susceptibility or neurasthenia connection. 

Prognosis. 

When displacements give rise to symptoms of ovarian irritation, 
what is the prospect of relief? 

Such cases are justly regarded as very unpromising, but not neces- 
sarily incurable. 

Treatment 

The treatment of the symptoms attendant, and to some extent de- 
pendent upon displacements of the ovaries, is sometimes followed by 
most satisfactory results. By treating the symptoms, I do not mean 
the administration of medicines for the relief of nervous headache, 
hysterical convulsions, sleeplessness, etc., but the removal of those 
conditions from the system which encourage their manifestation. 



686 AFFECTIONS OF THE OVARIES. 

Whatever may have been the diathesis of our immediate ancestors, 
whether they were affected by diseases resulting from hypersemia or 
plethora or not, it is evident that we have fallen upon times when 
ansemia or hydremia among women is, to say the least, a very com- 
mon state of the general system. This is especially the case with a 
large proportion of patients suffering from ovarian irritation, either 
with or without displacements of the ovaries, and the nerve centres in 
such people are habitually anaemic. 

Xervous exhaustion means imperfect nutrition or lack of trophic 
energy in the nerve centres. This, I have no doubt, is mainly because 
there is not a sufficient amount of good, rich blood circulating through 
them. 

I cannot understand how nervous exhaustion can take place when 
there is an unfailing supply of nutrition in these centres, but it is 
plain that an exhaustion of supply will render the regular working of 
the brain and spinal cord impossible. It is blood exhaustion, then, 
instead of nerve exhaustion. 

What we want to do with these patients is to turn them entirely 
around in their habits, and lead them to the adoption of measures 
that will make them plenty of blood and fat. Dr. S. Weir Mitchell 
has taught us how to do this, and his system of managing patients 
of this character is admirable. It is not always practical, nor, indeed, 
necessary to adoj3t his method as a whole. This, however, does not 
detract from its merits. Absolute rest is necessary only in cases of 
extreme prostration. 

In most cases active exercise will be better than passive, and should 
always be enjoined upon the patient and attendants. The exercise in 
kind and quantity should be prescribed and enforced with exacting- 
regularity, and urged by decision that will not fail. 

The most important part of the treatment, however, is the regulation 
of food, by which I mean the prescription of it in items and quantity 
from day to day. 

My routine prescription is three ounces of beefsteak for breakfast, 
with bread and butter, or toast, potatoes, and other vegetables, as the 
capacity for digestion will allow ; six ounces of roast beef or mutton, 
bread and butter, potatoes, vegetables, etc., for dinner ; for supper the 
same as for breakfast, and after each meal, and at bedtime, one pint 
of good fresh milk. The only limit I would place upon the amount 
of food of the kind I have indicated is the capacity of the stomach to 
retain it. If the food is not rejected by vomiting, or it does not irri- 
tate the bowels enough to cause diarrhoea, I would not allow the want 
of appetite nor the inconvenience that may arise during digestion to 
be considered as a reason for not taking it. Usually the stomach will 
soon become tolerant, and after a time, the enriched blood, circulating 
through its glandular apparatus, will engender a relish for food, and 



TREATMENT. 687 

the patient will eat with pleasure. This intimation, that an anaemic 
stomach necessarily digests with difficulty, is intentional, for I do not 
believe that energetic innervation is possible unless the supply of 
blood is sufficient to secure good digestion. 

With this, or some other equivalent method of feeding the patient, 
there should be associated some plan by which she can get plenty of 
fresh air, and have as much exercise as she is able to take. The ex- 
ercise may be passive at first, but as soon as it is possible it ought to 
be active. 

Active exercise may be begun by having the patient walk, sup- 
ported as much as necessary by a strong nurse, but as soon as she can 
walk alone the support should be withheld. Then it is not rest, 
but exercise, that should be advised in these cases. Of this I am 
fully convinced by experiments and unmistakable proofs in my own 
practice. 

As long as nutrition can be supplied the patient will profit by ex- 
ercise, but if nutrition is impossible, then of course exercise is impos- 
sible also. Thus far I have said nothing about medicines to aid 
digestion or to increase nerve force, not because I have no faith in 
them, but because I believe them of secondary importance, mere ad- 
juvants instead of principals in the treatment of this condition of the 
system. 

I could cite a number of instances in which this course of manage- 
ment averted the dangers and mutilation of the more heroic treatment 
of castration, by establishing a vigorous and tolerant condition of the 
nerve system, and thus curing ovarian irritation. These suggestions 
are applicable to cases other than displacements of the ovaries in 
which there is ovarian irritation. 

As to the management of the displacement. In some few cases, 
when the ovaries are borne down by a displaced uterus, we may oc- 
casionally correct the displacement so far as to greatly improve the 
circulation of these organs, and thus remove a great element in ova- 
rian distress. This, of course, is done by correcting the displacement 
of the uterus, by proper means of support, as a well-adjusted pessary. 

In the cases, however, in which the symptoms are the most grave 
— retroversion and retroflexion of the uterus, — the location of the 
ovaries in the cul-de-sac by the side of the fundus renders the satisfac- 
tory adjustment of the pessary almost impossible, as the instrument 
is pretty certain to cause pressure upon these sensitive organs, and 
thus become intolerable. We ought not to despair of accomplishing 
the object, however, until we have exhausted our ingenuity in mechan- 
ical appliances for this purpose. 

When every other measure fails either to render the condition of the 
patient bearable, or save her from becoming a mental and physical 
wreck, we still have the resource furnished us by Dr. Battey, namely, 



/ 



688 AFFECTIONS OF THE OVAEIES. 

the removal of these organs. In taking the consequences of this 
operation, however, we should remember that it is a dangerous one, 
and that, if successful, it unsexes our patient in the sense that she is 
at least barren for all future time. When the ovaries are displaced so 
as to occupy the inguinal canal, the operation for removing them is 
less hazardous than when in the pelvic cavity, and for that reason- 
may be resorted to with less hesitation. 

Acute Ovaritis. 

Acute inflammation of the ovaries, in connection with local perito- 
nitis, or inflammation of the cellular tissue in the pelvis, is not an 
uncommon affection. As simple, uncomplicated disease, however, it 
is conceded to be of infrequent occurrence. Post-mortem examina- 
tions reveal the existence of inflammation of the ovaries, as a compli- 
cation of inflammation of the surrounding tissue, in all stages, from 
mere phlogistic hyperemia to destructive suppuration. In such in- 
stances it is involved in the general mass of disease. This occurs after 
abortion, labor at full term, and even in the non-puerperal condition, 
as the result of cold. As ovaritis in this connection is a disease 
causing no separate symptoms, and requiring no other treatment than 
is necessary for the cure of the inflammation accompanying it, all that 
is requisite to say upon the subject will be found under the head of 
perimetritis. 

As the result of the infrequent occurrence of ovaritis in an uncom- 
plicated state, our knowledge of it is very meagre, many experienced 
practitioners never having recognized it. The intense interest the 
profession now feels and manifests in diseases of women will soon lead 
to a clearer understanding of this subject. 

The following case is the nearest approximation to simple acute in- 
flammation of the ovaries ever observed by the author : 

"January 5th, 1872, I was called to see Mrs. S., widow, aged thirty-five years. She 
is the mother of three children, the youngest of whom is eight years old. She had 
been attacked fourteen days before with pain in the hypogastric and iliac regions; 
chill, nausea, headache, and great nervous excitement. Fever succeeded the chill, and 
the nausea was sometimes accompanied by vomiting. The pain continued, and was 
aggravated by the erect or sitting posture. She was attended by a homoeopathic prac- 
titioner, and after a few days improved until she was abfe to sit up a part of the time ; 
but the pain, accompanied with tenderness upon pressure in the iliac region, contin- 
ued in a subdued degree. Upon the 13th, about 10 p.m., after having exerted herself 
too much, she had another chill, with an aggravation of the symptoms. In the morn- 
ing, when I was called, I found her vomiting, and unable to retain anything but cold 
water. She had headache, with pain and tenderness in both iliac regions. There was 
no tumefaction. The pulse was 110 to the minute; the tongue was coated white; the 
mouth dry, and other febrile symptoms usual in moderate attacks of acute inflamma- 
tion were present. The attack had occurred at the time the menstrual flow was subsid- 
ing, and was attributed to exposure after being overheated and fatigued. At the time 



CHRONIC OVARITIS — OVARIAN IRRITATION. 689 

I saw her there was no discharge from the vagina ; the passage of the urine gave her 
pain of a burning character, and she suffered pain also in passing the fasces. Upon 
examining per vaginam with the finger I could feel both ovaries prolapsed and tender. 
The uterus was prolapsed somewhat ; also swollen and tender to the touch. Upon 
making pressure in the hypogastric region the patient complained of but little tender- 
ness. Downward pressure in the iliac region caused more pain, and increased the sen- 
sations of tenderness in the pelvis. The ovaries, as felt through the vagina, were 
tender, movable, and appeared to be three times their natural volume. The patient 
complained of increased nausea when they were touched in the examination. I found 
no difficulty, by using the fore and middle fingers, in examining them thoroughly and 
recognizing their shape and size. The diagnosis was moderate inflammation of the 
uterus, with more acute inflammation of the ovaries. The patient informed me that 
she was not aware of being the subject of chronic inflammation of the uterus, as she 
had not previously suffered from pelvic pain or inconvenience, indicating chronic dis- 
ease of any kind about the uterus or ovaries. There did not seem to be local perito- 
nitis or cellulitis, and but slight metritis. The bladder was irritable, and the vagina 
slightly tender. 

" Treatment. 

"Four grains of calomel were given, and succeeded in eight hours by a saline ca- 
thartic. Poultices were applied to the hypogastric region, and the patient was ordered 
to keep quiet in the recumbent posture. The cathartics operated well, and relieved 
much of the pain and suffering. One-fourth of a grain of morphia enabled her to rest 
with some degree of comfort. When the pain returned the morphia was repeated, and 
thus continued when necessary for the pain. The bowels were kept soluble by the 
administration of a fluidounce of the saturated solution of citrate of magnesia. By 
continuing this course of treatment for six or seven days the inflammation was sub- 
dued, and convalescence was fairly established. In three or four weeks she was 
entirely well, and still remains so." 

Chronic Ovaritis — Ovarian Irritation. 

An extensive array of grave symptoms have for a long time been 
imputed to morbid conditions of the ovaries ; and while our informa- 
tion is yet meagre as to the exact nature of the pathological changes 
in the ovaries, and their relation to the symptoms, I think it may be 
said that within a few years past our knowledge in these matters has 
been decidedly advanced. This advancement is mainly attributable 
to the recent practice of removing the ovaries as a therapeutic meas- 
ure. The efforts to define by terms the morbid conditions of the 
ovaries when found diseased, so far as I know, have not resulted in 
anything of much value. When removed by the surgeon, statements 
as to their condition have been too vague to convey to the reader an 
accurate idea. Almost everything as to ovarian pathology has yet to 
be determined. 

In venturing to place the above heading to this section, I may be 
subject to criticism, and possibly correction by some one better in- 
formed upon the subject. It will probably be found that the reflex 
symptoms may be caused by more than one pathological condition of 

these organs, 

44 



690 AFFECTIONS OF THE OVARIES. 

Mr. Lawson Tait in his late work on Diseases of the Ovaries has 
described hyperemia and chronic ovaritis. 

In many cases in which the nervous and other disturbances were 
sufficient to require oophorectomy, a common condition and one fre- 
quently found in my own cases, was an unusual number of cysts, 
doubtless from ovisacs. And judging from such examination as I 
could make, these cysts contained the same kind of albuminoids that 
are found in large ovarian cysts. I believed them to be nothing more 
nor less than ovisacs developed prematurely and imperfectly (imper- 
fectly in reference to both the contents and containing tissues), and 
to be the result of a hypergenetic influence in the ovaries produced by 
long-continued hyperemia. 

Dr. Goodell* thinks that sometimes the inflammation affects the 
stroma more than the follicles and the converse. However this may 
be, there is often hypertrophy of both these tissues. I say hyper- 
trophy because I know of no more appropriate term. It is not, how- 
ever, simple increase of growth in either of these tissues, because the 
form of nutrition in them is not normal. In the stroma the increase 
is inflammatory deposit, and, as before said, the fluid in the follicles 
while it somewhat resembles, it is not identical with their normal 
contents. 

Etiology. 

Without further discussing the subject of the nature of the changes 
in the ovaries to which the term chronic ovaritis is here applied, I 
think we will find reason to believe in the correctness of it in the 
more frequent causative conditions. Scarcely any observer will doubt 
that by far the greatest number of instances succeed the acute form, 
and are accompanied by unquestionable inflammatory changes in the 
surrounding organs and tissues. Both acute and chronic ovaritis are 
generally secondary; the inflammation invades the ovaries from con- 
tiguous parts, as the broad ligaments, peritoneum, and especially the 
Fallopian tubes. It is now generally believed that gonorrhceal in- 
flammation, by passing through the tubes, reaches the ovaries. Many 
cases arise no doubt during the progress of the continued fevers. I 
think also that instances of acute inflammation in the pelvis and 
lower abdomen, causing ovaritis, are often mistaken by careless ob- 
servers and reported for typhoid fever. Whether there is any con- 
siderable tendency to ovaritis in the eruptive or rheumatic fevers, as 
asserted by Mr. Tait. I do not know. Excessive and prolonged sexual 
excitement, the rigid discipline at some of the more strict academies 
and other schools, constipation, and in fact anything that causes pro- 
longed hyperemia of the pelvic organs, will affect the ovaries in this 
way. 

* Pepper's System of Medicine. 



SYMPTOMS. 691 



Symptoms. 



These are local, general and functional. Prominent among the 
local is pain in the region of the ovaries radiating into the back, up 
the sides, and down the limbs. If the disease is confined to one of 
the organs, the pain and suffering may be manifest on that side alone. 
Pain in the course of the anterior crural or sciatic nerve may be the 
most prominent local symptom. Not unfrequently the pelvic pain 
will be increased at the time of menstruation, constituting ovarian 
dysmenorrhcea. 

There is no doubt that this affection produces decided effects upon 
the functions of the organs of generation, causing sterility, monor- 
rhagia, amenorrhcea, etc. ; also the abortive development of the ovi- 
sacs, as shown by their arrest of growth and their immature contents, 
the discharge of imperfect ova, etc. I have already expressed myself 
as believing that the numerous cysts formed upon the ovaries are im- 
perfectly developed ovisacs, the imperfections consisting mainly in 
arrest of development in both the involucra and their contents. As 
there is no question of the continuous impression of the ovaries on 
the uterus regulating its constitutional changes and functions in 
health, so I believe that when morbid their impression will be vicious. 
Facts adduced by Mr. Tait go far towards proving that when there is 
chronic hyperemia of the ovaries, there is the same condition in the 
uterus, and that this gives rise to monorrhagia ; also that when the 
inflammation has reached the stage of induration, amenorrhcea re- 
sults. This is but another expression of the principle that the gen- 
erative organs are so closely bound together by the same set of nerves 
and vessels that the condition of all of them is apt to be very much 
alike, anaemic, hypersemic, etc. 

The general symptoms are manifested in and through the nervous 
system, including the brain and spinal cord. In fact it is the kind 
and degree of disturbance in the nervous centres that constitutes one 
of the most important features in our estimate of the gravity of ovarian 
disease. The nervous symptoms are so varied that it is difficult to 
enumerate, much less describe them. 

I would refer the reader to the chapters on hysteropathy for a gen- 
eral view 7 of the symptoms of disease of the genital organs, believing 
that these symptoms would fairly represent those occurring in ovarian 
as well as uterine disease. With reference to the nervous symptoms 
mentioned in those chapters, the more grave are now almost uni- 
versally attributed to ovarian disease, and no doubt this is correct. 
Such symptoms are convulsions of varied intensity, and, mental de- 
rangements. When the convulsions are epileptiform they are called 
hystero-epilepsy, but perhaps ought to be denominated oophoro- 
epilepsy. As I have witnessed them in their severer forms they re- 



692 AFFECTIONS OF THE OVARIES. 

semble epilepsy so closely that I have been unable to distinguish be- 
tween them, and why may they not be true epilepsy and yet be of 
ovarian origin? As an aura may originate in a wound, why may it 
not begin in a diseased ovary ? 

One patient of mine w T ho had unquestionable epileptic seizures 
which lasted for many years was cured by having both ovaries re- 
moved. One ovary was included in a large ovarian tumor, and the 
other was found occupied by numerous small degenerate cysts. 

This hystero-epilepsy often results in great impairment of the mind, 
in fact this danger is one of the justifying conditions of oophorec- 
tomy. Mental derangement, however, does not always come about as 
a result of long-continued convulsions, but often seems to be a more 
direct consequence to ovarian disease. One of the tests usually applied 
as proof of ovarian origin is the repetition or aggravation of the attacks 
at the time of the menstrual period. There is generally something of 
a correspondence of this kind, but I think not always ; for the parox- 
ysms may occur at regular times between the menstrual periods. 

Diagnosis. 

As the ovaries in a state of inflammation are larger and heavier 
than natural, they not infrequently come within reach of the finger 
in vaginal touch. When not enlarged or somewhat displaced, it may 
be very difficult for the physician to demonstrate to his satisfaction 
what their condition is. When they are down within reach of the 
finger in the vagina their shape, size and sensitiveness may be to a 
certain extent ascertained. The roughness and unevenness caused by 
cystic degeneration when present may generally be appreciated. A 
perfectly normal ovary ought not to be very sensitive, and hence I 
regard tenderness as a sign of inflammation. In very thin persons, 
by the bimanual examination, the ovary can often be felt when in 
situ. They are sometimes reached through the rectum, and when ex- 
actitude in diagnosis is important, two fingers or the half hand should 
be introduced into the rectum, when the ovaries may be brought 
under inspection. Another item of great importance in the diagnosis 
is as to whether the grave secondary symptoms, such as mental de- 
rangement, convulsions, etc., depend on ovarian irritation, or disease 
of the nervous centres themselves. A few very important considera- 
tions are : 1st. Is there evident ovarian disease of a serious character 
present? 2d. Have the nervous disorders made their appearance 
since the establishment of the pelvic trouble? 3d. Are the nervous 
symptoms aggravated at or near the menstrual period, or are they 
worse at some regular period during the menstrual interval? 4th. Is 
there an absence of hereditary tendency to diseases of the brain ? An 
affirmative answer to all these questions makes the probability of 
their dependence on disease of the ovaries quite strong. 



PROGNOSIS COMPLICATIONS — TREATMENT. 693 

Prognosis. 

Is the prognosis of chronic ovaritis so grave as we have been in the 
habit of considering it ? I think not. On the contrary, I believe it 
is often cured, and more frequently the suffering of the patient is 
ameliorated until the menopause comes to her relief. The prognosis 
in those serious cases where the nervous centres are so severely 
affected that their functions are threatened with permanent disorder 
may be regarded as desperate ; but these are fortunately not the most 
common form. The prognosis is rendered desperate because the 
reflex effects of ovarian irritation are destroying the patient so rapidly 
that we cannot wait for the slow operation of a medicinal course of 
treatment, and hence are obliged to resort to surgical measures. There 
are a great many cases where the morbid conditions do not produce 
these symptoms and consequently do not demand such radical means 
of relief. In all grades of the disease the cure is slow. It is usual to 
consider the anaemia and nervous prostration as the direct effects of 
the morbid ovarian impression, but I believe that the degeneration of 
this structure is often the consequence of long exhausting and vitiat- 
ing general conditions. 

Complications. 

Chronic ovarian inflammation is nearly always accompanied with 
inflammation in other organs or tissues of the pelvis. The most com- 
mon are local peritonitis, cellulitis and salpingitis. But the uterus 
very frequently is also implicated. Sometimes there is displacement 
of the uterus and ovaries, the latter lying under the retroverted or 
retroflexed womb. When the erect posture causes them to be pressed 
upon painfully, and when they are in a position to be seriously dis- 
turbed during coitus, the grave nervous symptoms so frequently 
present stand in the relation of consequences rather than complica- 
tions. 

Treatment. 

The treatment will be greatly modified by the stage of the disease 
and intensity of the reflex symptoms. Until the functions of the 
nervous centres are very much disturbed, we may depend upon gen- 
eral and gynecological treatment with the hope of effecting a cure. 
When, however, there is either incipient or established insanity, epi- 
leptic or hystero-epileptic convulsions, and especially if the disturb- 
ance to the brain usually brought about by these affections is increas- 
ing, we must regard surgical measures as essential to a cure. Mr. Tait 
mentions another symptom as being equally unmanageable without 
surgical measures, viz., excessive and obstinate menorrhagia. Possi- 
bly other conditions connected with chronic ovaritis may as urgently 
demand oophorectomy, but I think they must be very few. In those 



694 AFFECTIONS OF THE OVARIES. 

cases in which a multitude of derangements of minor importance 
exist, and in most of which nervous prostration is predominant, 
we may reasonably expect, if not a complete cure, very great benefit 
from judicious general treatment. One object greatly to be desired is 
improvement of the general healthy In bringing this about we do 
not, as might be supposed, merely palliate the sufferings of the pa- 
tient by making her better able to bear them, but we create re- 
cuperative energy. An improvement in the condition of the blood 
and nerve force is necessary for the cure of any chronic disease. A 
woman cannot be cured of chronic ovaritis while in a state of great 
nervous prostration or profound anaemia, and the removal of these 
complications goes a long way toward the cure. The systematic feed- 
ing, massage, electricity, and mental rest so admirably taught and prac- 
ticed by Dr. Weir Mitchell, forms an excellent method of inaugurating 
the treatment of these cases. This followed up by travel when that 
can be indulged in will often be sufficient to restore the patient. 
When neither of these are practicable we can generally imitate the 
former sufficiently well to produce much the same effects upon the 
patient. We can prescribe the quantity and kind of food and fre- 
quency of taking it, the character and amount of outdoor exercise, 
according to her circumstances and ability to afford it. This plan is 
generally practicable even with people in moderate circumstances, if 
the physician will properly study the matter. (See General Treat- 
ment of Uterine Disease, from pages 397 to 415.) 

Another probably not less essential part of the treatment is the 
correction as near as possible of every abnormal condition found in 
all the associate organs, the uterus, vagina, tubes, etc. With the ex- 
ception of displacements, the remedies addressed to the diseases of all 
the pelvic organs affect the ovaries as well. For chronic inflamma- 
tion of the uterus and broad ligaments, we prescribe the Jiot^vater 
douches, sitz-baths, glycerin tampons, iodine counter-irritation, etc. 
And these used perseveringly are precisely those from which we would 
expect the most good in cases of chronic ovaritis. 



CHAPTER XLIL 

AFFECTIONS OF THE OVARIES (Continued)— OVARIAN TUMORS. 

Anatomy. 

In the ovarian tumors proper, we may trace three coats or layers 
of tissue forming their walls. The external is the serous or perito- 
neal. It is shining and smooth as this membrane is elsewhere, and 
seldom changed in any way, except it may be thickened and hyper- 
trophied. It can be traced into the peritoneal covering of the viscera 
and abdominal parietes, and consequently needs no elaborate descrip- 
tion. The internal coat or lining membrane is doubtless the mem- 
brana granulosa of the ovisac, very much hypertrophied. When 
small, something like epithelium seems to be its entire composition. 
As it grows and develops, the epithelial arrangement is less perfect, 
until, when very large, we can observe it only in patches. In many 
cases when thus large, this membrane has a smooth, lustrous appear- 
ance, but in others it is more or less thickly studded with granular 
projections, varying from almost imperceptible minuteness to the size 
of peas, or even larger. Regarding the main sac as an hypertrophied 
ovisac, I think these little granular sacs (for they prove to be sacs 
upon examination) are also of the same nature and are the origin of 
the numerous endogenous or supplementary growths which constitute 
one of the polycystic varieties. 

The middle coat is made up from the stroma of the ovary. Its 
strength depends upon quite a considerable amount of fibres, which 
enter into its composition. As the tumor develops, these fibres are 
enlarged, and apparently, if not really, increased in numbers, until 
they constitute the most of the thickness of the walls, and in some 
parts make quite a thick, dense, and tough tissue. These qualities 
are greater in old large sacs than in the smaller and younger ones. 
At the pedicle, and for some distance up the sides, they are greater 
than in other portions, being in these parts sometimes a quarter of 
an inch thick, while at the fundus or distal portion they may be 
thin and fragile. The whole of this coat may be very tough and 
thick, so as to resist great force, or it may be thin throughout, so as 
to be easily ruptured at almost any point. Entangled in the meshes 
of these fibres may be discovered, in many cases, the minute micro- 
scopic points so numerously scattered through the substance of the 
ovaria. These points are believed to be the origin of the germinal 
spot in the ovum by some physiologists, and around which are de- 



696 OVAKIAS TTMOBS. 

veloped the ovum, and progressively the whole ovisacs and their eon- 
tents : and I believe that their presence in the walls of the tumors, 
over much, if not the whole, of their extent, accounts for the devel- 
opment of the minnte grannlar internal projections above described. 
In a tumor recently removed from the body, by holding it up to the 
light, we may not unfirequently discover the peculiar buffy tinge seen 
in the stroma. The vessels are situated in this coat. They are 
numerous and some of them large, so large that great care is neees ; : 
to prevent them from bleeding when the peduncle is divided. They 
are developed, it is hardly necessary to say. to this great size from 
the minute twigs which penetrate the substance of the ovary. 

The shape of ovarian tumors may vary much. They may be regu- 
larly globular, polyglobular, angular, or irregular in aim:-: every 

AMien small, the ovary may be seen as constituting a consider- 
able portion of the tumor. When large, the ovary may be almost 
lost in the walls, or observed as a mere tubercle sticking to or im- 
bedded in its side. Generally but one ovary is the seat of disease, 
but in rare instances both are affected. Ovarian tumors divide them- 
selves anatomically into moDocystic and polycystic, — the one having 
a single cystic cavity, the other several. The polycystic vane: is 
formed by the development of several cysts adjoining or by the side 
of each other, and independently attached to or springing from each 
other on the external surface, or within the cavity of one large one. 
The instances of polycysts growing by the side of each other, and 
being independently attached, resembles at first the monocysts. At an 
early stage of development they may stand free of contact one with the 
other, but as they grow in size, in consequence of the small surface 
of the ovary to which they are attached, they crowd together, so that 
it is not always easy to say whether they were not developed from 
each other. The cysts from which smaller ones grow are called pro- 
liferous. They are doubtless single for some time in their early 
development, but carrying up, as they increase in size, the proper 
substance of the ovary, with its rudimentary ovisacs, after awhile the 
inner or outer surface is bulged by the maturity of these last, which, 
if they do not dehisce and allow the escape of the ovum, grow into a 
subordinate tumor. This process is separate until there is a glomera- 
tion of cysts to quite a number, from four to fifty, of various sizes, 
from the size of a man's head down to that of a pin's head. Small 
- may be so numerous as to stud a large part of the inner surface 
with granulated elevations. This is the most frequent variety met 
with in practice. When the minor sacs grow from the inner surface 
of a large cyst, the tumor is denominated oligocystie. 

There is a great difference in the sensible qualities of the contents 
of the cysts in different cases, and of the different cysts in the same 

In some i: > thin, in others very thick and tenacious, 



NATURE AND ANATOMY. 697 

while the color shades from black, inky, to limpid clearness. Not 
unfreqnently large fibroid growths are observed in the ovary at the 
base of a single or multiple cystic tumor. These solid fibroid or 
fibrous growths may be simple or benign in their nature, or malig- 
nant. This complication of ovarian dropsy I think is more frequent 
in persons advanced in years — over forty — than in younger ones. The 
contained fluid of the polycystic tumor is ordinarily highly albumi- 
nous, of high specific gravity, tenacious, and more or less colored. 
The fluid is sometimes so thick as not to flow through a canula. 
Occasionally we meet with sacs which contain blood ; more frequently 
serum colored with blood ; in others pus, or serum and pus. From 
one tumor of several cysts, I drew pus from one cyst ; dark coffee- 
grounds sanguineo-serous fluid from another ; a beautiful straw color 
from another ; and lastly, from another, fluid of a delicate azure tint. 
After tapping, more or less alteration is observed in the fluid, each 
operation withdrawing fluid affected by chemical or pathological con- 
ditions. In the former, putridity or acridity ; in the latter, the puru- 
lent productions of inflammation. 

There are some chemical and microscopic resemblances in the fluid 
from almost all varieties of ovarian tumor. Albumen in some of its 
forms is always present. In some specimens of fluid, strong acids, 
or ,heat, cause it to assume a solid form, coagulating and adhering 
like the white of an egg when cooked in boiling water ; in others a 
small precipitate is all that is observed. Between these extremes all 
shades of difference exist. The reaction is alkaline. Mr. Nunn 
says that, " As the results of many examinations (microscopic) of 
different specimens of ovarian fluid, the most constant characteristic 
of such fluid is its containing, in greater or less abundance, cells 
gorged with granules; and, in addition, circumambient granules, 
having the same measurement, encompassed by the cell. The size of 
the gorged cells and included granules varies greatly, even in fluid from 
different cysts in the same ovary." This description of fluid could, 
with certainty, remain good of the first evacuation only, as pus and 
blood-globules are not unfrequently found in subsequent evacuations. 

The fibrous or solid variety of ovarian tumors is occasionally met 
with. Dr. Bogue, about ten years since, removed a solid tumor of the 
ovary at the Cook County Hospital, which weighed forty ounces. It 
was very dense and fibrous in structure. 

The very remarkable tumor called dermoid is so seldom met with 
and so little is said of them in the textbooks that I feel justified in 
copying somewhat at length from my article on dermoid ovarian 
tumors, in the third volume of the Transactions of the American Gyne- 
cological Society : 

Case I. — In the spring of 1874, the patient, a girl, eighteen years of 
age, noticed an enlargement in the left iliac region, which finally be- 



698 OVARIAN TUMORS. 

came so great that in October, 1875, she was distressed from the dis- 
tension. At this time she was tapped and about ten quarts of fluid 
evacuated. The fluid was somewhat tenacious, of a clear, slightly 
bluish tinge, and contained the ovarian cell. The outline of the tumor 
could be traced quite easily after the tapping. It occupied the whole 
width of the abdomen between the two iliac fossae and extended 
upwards to within two inches of the umbilicus. It was globular and 
of soft consistence. 

After this operation the tumor filled quite rapidly, and on January 
1st, 1876, the patient was as large as before the fluid was evacuated. 

On January 4th, ovariotomy was performed. There were no adhe- 
sions or other source of embarrassment to the removal of the tumor, 
and the patient made a good recovery. 

The sac was thin but firm, and presented the peculiarly pearly 
aspect of the ordinary ovarian tumor. When the large Wells's trocar 
was introduced nothing but serum flowed through the tube. Upon 
being opened the tumor was found to contain about half a pound of 
sebaceous fat. The inner surface was smooth, except a small part 
about the size of the palm of the hand situated at the bottom near 
the pedicle. Here the surface was depressed at least an inch below 
the level of the inner surface, and, although not sacculated, had a 
well-defined and pursy margin. The bottom of this depression was 
covered with dermic tissue, and upon it grew an abundant crop of 
dark-brown hair about an inch long. It was very fine, and firmly 
attached. Doubtless the dermic patch was the source of the fatty 
material found floating in the cyst which, on cooling, assumed the 
consistence and appearance of yellow butter. Upon closer inspection 
of the smooth lining of the larger part of the tumor it was found to 
be studded with very minute papillse, such as we sometimes see in 
oligocystic ovarian tumors. 

This specimen I regard as not a true dermoid cyst, but as a com- 
plex dermo-ovarian tumor, a tumor originating in a Graaffian follicle 
in which a tegumentary element had been inclosed. It contained no 
bone or teeth such as are often found in the true dermoid tumor, but 
did contain undoubted colloid fluid, diluted with the watery product 
from the sweat glands of the dermic membrane upon which the hair 
was implanted. 

Case II. — Mrs. P., aged forty-three years, the mother of one child, 
eighteen years old, became aware of an enlargement of the abdomen 
about ten months before the operation, which was performed June 
28th, 1876. During that time she grew to the size of pregnanc m y at full 
term. The tumor filled the abdominal cavity and extended to the 
ensiform cartilage. There was no difficulty in deciding that it was 
monocystic and contained a thin fluid. The operation was not 
attended with difficulty in any respect. There were no adhesions, 



NATURE AND ANATOMY. 699 

and after evacuation the sac passed through an incision only three 
inches long. The patient experienced considerable depression from 
the shock of the operation. This, however, lasted but a few hours, no 
other disagreeable symptoms supervening. The recovery was rapid. 
The care of the case after the operation was undertaken by Dr. S. W. 
Green, of Marengo, Illinois. 

The cyst was single, thin, and uniform, except at the part opposite 
the pedicle, where its wall was about half an inch thick and contained 
a thick layer of adipose tissue. Upon the inner surface of this part 
was a thick tegumentary covering, upon which was implanted a dense 
mass of blonde hair, matted together, and nearly the size of an orange. 
The whole of the inner surface of the sac elsewhere was smooth and 
of a buff color. The external surface was of a pearly hue and smooth. 
There was no evidence of bony or dental tissue. The fluid was quite 
thin, of a slightly blue tinge, and floating in it in considerable masses 
were ten to twelve ounces of yellow sebaceous fat. The hairs, when 
straightened out, measured from six to fifteen inches in length. 

This example I regard as a simple dermoid cyst of the ovary, there 
being no sign of follicular papillae upon the inner surface, and the 
fluid not being in the least tenacious or colloid in appearance ; more- 
over, I was unable to find in it the ovarian cell. I think the fluid was 
the product of the sweat glands in the dermic structure at the bottom 
of the cyst. 

Case III. — Mrs. P., a small Jewess, thirty-one years of age, the 
mother of four children, the youngest being three years old, noticed 
about nine months before the operation — which was performed April 
7th, 1875 — that the abdomen had commenced enlarging. The tumor 
was found to be monocystic and so completely filling the abdomen that 
the patient had great inconvenience from distension. 

The removal of this tumor, which originated in the left ovary, was 
easy, as no adhesion or other obstacles were encountered. The patient 
recovered without experiencing any untoward symptoms. 

The tumor was composed of a single cyst, of which the wall was 
thin over about three-fourths of its circumference and easily ruptured. 
At the bottom or pedicular portion, involving about one-fourth of the 
inner surface, was a dense mass of areolar tissue literally filled with 
pieces of bone. The greater number of these pieces were cylindrical, 
from half an inch to two inches in length, and varying from an eighth 
to a quarter of an inch in thickness. They seemed to be imbedded in 
loose cellular tissue, were not attached to each other, and were easily 
removed by the finger. Other masses of bone, made up of alveoli, 
were not unlike the maxillary processes, and varied in length from 
one to two inches, and in width from one-third to one-half inch. They 
resembled honeycomb, and were quite firmly attached to the cyst wall. 
The microscope showed their structure to be that of true bony tissue. 



700 OVARIAN TUMORS. 

This mass was covered by a tegumentary membrane to which were 
attached more than a hundred imperfect incisor teeth, distributed over 
the whole surface, their adhesions being so slight that they could 
easily be scraped from the surface with the finger. These dental bodies 
were all about the same size, and consisted merely of the crown, but 
the enamel and dentine seemed perfect. They had no connection 
whatever with the bony tissue. Interspersed among these teeth was a 
dense crop of blonde hair, averaging an inch in length. 

The fluid, of which there was about 10 quarts, sp. gr. 1008, was 
clear, with a slight bluish tinge, and entirely devoid of tenacity or 
other colloid properties. I believed it to be perspiratory serum. There 
were also several ounces of yellow sebaceous fatty matter within the 
cyst. 

I should class this tumor among the true dermoid cysts of the ovary, 
and believe that it possessed none of the properties of the ordinary 
ovarian tumor. Its structure was much more complex than that of 
the tivo preceding tumors, but much less so than that to which I shall 
now call attention. 

Case IV. — Mrs. B., thirty-five years of age, the mother of four chil- 
dren, the last twenty months old, first noticed a tumor in the right 
iliac region nine years before operation. It was then about the size of 
her fist. It had grown steadily but slowly until June 19th, 1878, when 
it was extirpated. The growth did not seem to be influenced by 
pregnancy. She had borne three children from the time when the 
tumor was discovered to the time of its removal. Her health had been 
feeble for several years, but from the birth of her last child she had 
been confined to bed half of each day, and, for several weeks, all the 
time. The main inconvenience was from the weight and mobility of 
the tumor. When she was in the erect posture it caused dysuria and 
rectal tenesmus ; when lying on either side it pressed upon the subja- 
cent viscera and also dragged upon the upper side ; the only com- 
fortable position was the dorsal. The pulse and temperature were 
decidedly and continuously above the normal standard. She was 
sleepless, had a very poor appetite, and was rapidly becoming ema- 
ciated. The above very brief history was given me by the attending 
physician, Dr. J. H. Low, of Brimfield, Illinois. 

The appearance of the abdomen was very singular. It was con- 
siderably distended ; from its centre, including in fact the whole 
umbilical region, arose a round projection exactly resembling a ven- 
tral hernia, the umbilicus occupying its apex. It measured five 
inches in diameter, and protruded three and a half inches above the 
common level. It was fluctuating and dull upon percussion. On 
each side I could easily distinguish two other, apparently larger, cysts 
not projecting above the surface. Percussion over these elicited no 
resonance, but it was easy to detect fluctuation. The tumor could be 



NATURE AND ANATOMY. 701 

moved pretty freely in all directions without traction upon any part 
of the abdominal walls. By external and internal manipulation I 
could trace the attachment of the mass to the right side of the pelvis 
and assure myself that it w r as not of uterine origin. It was clear that 
I had to deal with a tumor made up, principally at least, of three 
cysts, and quite certainly originating in the right ovary, but it pre- 
sented so many unusual symptoms and appearances, that further 
diagnostic measures were necessary before I would venture to remove 
it. After making preparations for its extirpation, the patient being 
fully etherized, I introduced a small trocar into the prominent cyst. 
A little sebaceous fat flowed through the canula, and at once made 
the diagnosis complete. The usual small incision exposed the pearly 
cyst and allowed me to evacuate the prominent sac of one quart of 
thin, yellow fat. The other two cysts were drawn to the opening, 
and their contents, of a similar character, evacuated. By this time 
the rubber blanket was smeared with a sticky grease, the instruments 
had become slippery, and my fingers were encumbered with a mass 
of fat which had to be removed before I could proceed with the 
operation. The cysts were drawn through an incision about three 
inches long, and a short, slender pedicle, consisting of the right 
ovarian ligament, part of the broad ligament, and Fallopian tube, 
w r as brought up into the wounds, ligated, cut, and dropped into the 
pelvic cavity. The left ovary w T as healthy. As nothing had been 
allowed to pass into the peritoneal cavity the incision was then closed. 
It will have been seen by this description that no adhesions or other 
impediment hindered or complicated the operation. It was remark- 
able how extremely greasy everything employed in the operation 
became, and I had more trouble in cleansing the instruments from 
the grease than is usually experienced in getting rid of the blood and 
mucoid fluid of the common ovarian tumor. The patient had no 
untoward symptoms, seeming to me more like one recovering from 
the exhaustion and irritation in which I had found her than from the 
hazardous operation for the removal of an ovarian tumor. 

Before describing the tumor I wish to call attention to the fact 
that there was no serum evacuated during the operation ; no fluid but 
the soft fat was observed. The tumor proved to be a remarkable 
specimen of the true dermoid variety, nothing in its contents seem- 
ing to be of ovarian origin. The cyst wall was thin, but of firm 
structure, and divided into three compartments of about equal 
dimensions. The septa were complete, and of the same consistence 
and density as the external wall. At the base of the tumor the sac 
was more dense and firm than elsewhere. The peculiar formations 
contained in each cyst were so nearly alike that a description of the 
contents of one will suffice for each of the other two. 

On opening the cysts each was found to contain a mass of matted 



" _ OVAKIAX TUMORS. 

hair, the size of a lemon, thoroughly supplied with the same fatty 
substance that had been evacuated from the tumor. One of these 
rolls of hair ws - : another blonde, and the other gray. The pa- 
tient's hair was dark brown. Some of this hair was twenty inches 
long, and it was all attached to tegumen: substance closely re- 
sembling the scalp. The dermic structure, which was about four 
inch— : — :- ; :ed upon a very uneven layer of adipose tissue an 
inch thick. By the side of the dermic patch, and not covered by it. 

- a loose layer of areolar tissue, an inch and a half thick, contain- 
ing bones in a great variety :: shapes. — scales, round bones an inch 
or more in length, alveolar nodules, etc. V :n the surface of this 
part of the tumor in each -: was half-arch of teeth the shape of 
one-half the superior maxilla. In one cyst the crowns of the teeth 
projected above the surface, while in the other two they were thinly 
Tied by tissue - : soft that it could be pinched off by the thumb 
and finger. The teeth were not attached to the subjacent bones, but 
w jre simply imbedded in the loose mass. The teeth in each segment 
" oerfectly represented, respectively, an incisor and three molars, 
each having three well-marked fangs. One of the molars in each row 
strong resembled the wisdom tooth. The perfection of their forma- 
tion will be recognized in the specimens which I submit for your 
examination. The crown with the enamel and eminences, the main 
body, and roots are as distinctly marked as if they had been removed 
from alveolar cavi:ir~. 

Erfore leaving the description of the tumors and their removal. I 
would call your attention to the great simplicity of the operation and 
the fortunate recovery of all the patients, no adhesions or other com- 
plications having exis:^ 

N : w what is a dermoid tumor? This name is given to a cyst 
formed anywhere in the body, the internal or lining membrane of 
which is in part or wholly tegumentary in structure. As now un- 
derstood, the presence of this condition alone would justify this 
nomenclature. The formation seems to be no less an error of struct- 
ure than location. Lebert, Paget^ Virchow, and most other modern 
pathologists agree that the dermic tissue thus located is essentially the 
same in structure as true skin. The products are all the same, hair, 
sebaceous fat. and perspiratory fluid. In many of these tumors we 
find subcutaneous lij >se tissue very perfectly formed. Less con- 
stantly, teeth, bone, muscidar, nervous, and even brain tissues. These 
latte I the teeth, in some instances, are found either beneath 

the dermic membrane or beneath the portion of the internal surface 
not lined by this cutaneous substance. 

My observation shows that the dermic tissue and its products char- 
acterize one var; ety I "hese formations, as in Cases II and III. 
These constituents are sometimes found alone, and mav then be re- 



NATURE AND ANATOMY. 703 

garded as indicative of a more simple formation, while the addition 
of bone, muscle, etc., constitute a more complex order of tumor rep- 
resented by Case IV. The bone and muscle, however, are never 
found in a tumor of this kind without the dermic membrane, its 
essential glands, and their products. Another thing quite apparent 
is that the skin and its appendages are not only constantly present, 
but comparatively perfect in their organization. The teeth, which 
are very closely associated in embryonic metamorphosis with the for- 
mation of the skin, stand next; many being quite perfect in their 
structure. The bony, muscular, and nervous structures, although 
complete in their texture and formation, are never developed into 
complete organs. I am aware that cases have been recorded, — as, for 
instance, by Blumbach and Rokitansky, — that w T ould seem to be at 
variance with this assertion ; but the bones in these cases lacked the 
completeness in structure necessary to entitle them to be classified 
with any of the bones in the human skeleton. When some or all of 
these structures, together with the products of the dermic tissue, con- 
stitute all the contents of the cyst, the specimen should be regarded 
as a simple dermic tumor, even when formed in the ovary, the fact 
of its having found a lodgment in that organ being an accidental 
rather than a necessary condition. When, however, it exists in the 
ovary, and with these substances there is found the colloid or mucoid 
fluid characteristic of the ordinary ovarian tumor, it is not merely a 
dermoid, but an ovarian dermoid tumor. It is a mixed neoplasm, a 
morbid development of the ovarian follicles in connection with the 
congenital dermoid. In my first case this was the character of the 
tumor ; and instances of this kind are recorded in the well-known 
books of Drs. Atlee, Peaslee, and Mr. Wells. The first variety, then, 
although often found in the ovary, differs in no essential particular 
from those found elsewhere, except in magnitude, and perhaps greater 
perfection of organized development. Possibly this last difference 
does not exist. 

When found in the ovary, either in the single or mixed form, the 
investing membrane seems to be the same in appearance and structure 
as in ordinary ovarian tumors; and, when first exposed, it is often not 
easy, if at all possible, to distinguish between them until some of their 
contents are evacuated. 

To the more fluid products of the first variety of simple dermoid 
cysts, especially the secretion from the dermic tissue, such as the serous 
or perspiratory fluid, we must attribute the difference in the size of 
this form of tumor. The sebaceous product is also sometimes quite 
bulky, as seen in Case IV ; but when the sudoriparous glands are 
numerous and active, the amount of watery fluid is sometimes enor- 
mous, and consequently the tumor grows to be very large, as may be 
specially noted in the second case. In such instances, from causes 



704 OVABIAN TUMOES 

which are not appreciated, the sudoriparous glands seem suddenly to 
acquire great functional activity, and by pouring into the tumor a 
large supply of fluid make it grow with great rapidity. 

As there was no appreciable amount of serum in Case IV. the sac 
being filled with the sebaceous matter, it is easily understood why the 
tumor was a long time in attaining the dimensions it finally acquired. 
The solid contents of these tumors, as far as I can learn, do not grow 
to a sufficient extent to give them any great bulk, and consequently, 
when situated in the ovary, such a tumor, apart from its fluid contents, 
would hardly require extirpation. 

The compound variety, or ovarian dermoid, would be likely to grow 
to a great size in consequence of the accumulation of the colloid secre- 
tion, just as they would if the dermoid element did not exist. By 
consulting the literature of the subject, I am led to the conclusion that 
the dermoid and colloid contents of these compound cysts are usually 
contained in different compartments of the tumor. This was notably 
the case in some of Mr. Wells's specimens. 

There are one or two facts which may have some bearing upon the 
production and development of these tumor%: The dermic membrane 
is always superficial with reference to the inner surface of the tumor ; 
the hair always, and the teeth often, grow from its surface : while the 
bone and other tissues are situated below it. but not always imme- 
diately under it. In my fourth specimen the bone was imbedded in 
a mass of cellular substance by the side of the cutaneous layer, giving 
me the idea that it belonged to a blastodermic formation deeper than 
the tegumentary portion of the surface. 

The question here naturally presents itself: Whether the simpler 
forms of these dermoid cysts, in which the dermoid structure, with 
hair. fat. and serum are found without any of the deeper tissues, are 
tumors in the process of development into the more complicated va- 
riety? I think not, and believe that each tumor receives during its 
embryonic state all the elements of formation it is capable of producing ; 
that the trophic qualities imparted to it then definitely limit its possi- 
bilities. If so. it necessarily follows that the tumor, containing all the 
variety of structure ever found in them, should manifest these qualities 
and structures without gradation of growth, and possess from the be- 
ginning the complex qualities found in advanced periods of life. 

Theories of their Origin. 

The theories devised to explain the origin and development of 
ovarian dermoid tumors represent, with some degree of exactness, the 
physiology of the times in which they originated. In the earlier ages 
of medicine, physiology was the creature of imagination. Definite 
knowledge of the internal organs was wholly wanting : if possible, 



NATURE AND ANATOMY. 705 

even less was known of their functions. Pathology also rested upon 
the same unsubstantial basis. As a consequence, the theories of the 
origin and development of these curious growths were all vague and 
imaginary. In the latest and most plausible explanation yet offered, 
we have the results of the present highly cultivated science of physi- 
ology ; and if not absolutely true, there can be fewer rational and 
scientific objections opposed to it than to any of its predecessors. 

It is not my present purpose to do more than give a very cursory 
view of some of the most prominent theories which have at different 
ages been presented to, and accepted by, a large portion of the pro- 
fession at the time they were promulgated. I will classify the theo- 
ries under three divisions : I. Those originating in the imagination 
alone without any scientific foundation. II. Those which have for 
their basis the superstitions of the times in which they originated, 
and of the people by whom they were entertained. III. The scien- 
tific theories. 

I. The most ancient of the imaginative theories is, I believe, attrib- 
uted to Aristotle. It taught that the dermoid products of these tumors 
— as the hair, teeth, etc. — had been swallowed and transmitted in some 
unknown manner to the localities occupied by them. This idea is a 
good match for many of the ingenious vagaries of that wise man. 

Belief in virginal pregnancy supplied the basis of another and ex- 
tensively prevalent theory. It assumed several forms. One was the 
abstract possibility of a virgin becoming impregnated without sexual 
intercourse, or true parthogenesis. Another was that the ovaries pos- 
sessed properties that enabled them to produce, to a limited extent, 
the organized bodies resembling the parts of a foetus ; or, again, that 
certain unsatisfied sexual longings of an isolated woman might stimu- 
late the ovaries to imperfect generative processes. 

Still another was that certain individuals possessed a sort of ovario- 
cystic diathesis which took this direction. 

It is easy to see that these vagaries— for they ought not to be dig- 
nified by the term theories — had no physiological basis and could be 
the products of imagination alone. 

II. The superstition of mediaeval times gave rise to the theory 
that these tumors were visitations of Providence upon the subjects of 
them on account of particular sins. The infliction. of this punishment 
upon males as well as females showed Providence to be no respecter 
of persons. One man had a pregnancy in the thigh because he laughed 
at his wife in her suffering during labor. It is said that the products 
of these tumors were sometimes baptized in the hope of avoiding the 
perdition in which they would be involved without such a ceremony. 
Hence, it seemed that the priests believed in their own invention, 
and that the theory was not a mere trick with which they tried to 
practice upon the credulity and ignorance of the people. 

45 



?0(i OVAEIAX TUMORS. 

III. As the knowledge of physiology advanced somewhat among 
the profession, the theories became more rational, and the possibility 
of natural causes was employed to explain the occurrence of these 
singular tumors. 

They were regarded by many as ovarian pregnancy, in which the 
formation of the foetus was imperfect, or, after having undergone 
development, the foetus had become disintegrated, and the skin, bones, 
and teeth being more difficult of destruction, had withstood decom- 
position and remained in the sac. Another theory accounted for 
their peculiarities by supposing that the ovum had become blighted 
after having been developed to a certain extent. 

§ me one else has propagated the doctrine of inclusion, or of a 
foetus in fcetu. believing that somehow one ovum had become en- 
gulphed in the organization of the other, and on account of the nature 
of its nidus could not attain to complete organization or develop- 
ment. 

Still later, plastic heterology and heterotopy were supposed to afford 
a more rational explanation of their production. According to this 
theory, the origin of these tumors in any part of the body is no more 
wonderful than the growth of other forms of heterologous tumors in 
the same localities. 

In the light of the patient physiological research of our own 
and especially from the revelations of the microscope, a theory of these 
curious tumors has been developed, which I regard by far the most 
satisfactory and scientific. 

This theory is based upon a supposition which is at least physio? 
logically plausible. It may be stated thus : 

In the early period of ovulation or embryonic development, by- 
some accident or imperfection of formation, an indentation of the 
blastoderm is produced. In the wonderful trophic energy of that 
period the minute depression is inclosed by the approximation of :: ; 
blastodermic margin and becomes an isolated cavity, and the growth 
and perfection of the embryo are accomplished notwithstanding this 
early accident to the integrity of its envelope. The depression thus 
formed involves, perhaps, all the layers of the blastodermic membrane, 
but the external layer becomes the lining membrane of the cavity, 
and is completely cut off from the rest of the blastodermic sui 
and invaginated with all its essential structures and processes : 
organization ; all its products, therefore, must be retained in the cavity. 
The contents of this cavity correspond in miniature with what the 
formation might have been if the displacement had not occurred. In 
the further development of the embryo the portion of the blastoderm 
covering this adventitious cavity develops its tissues and organs in 
the ordinary way, and thus incloses it in the body by the structures 
usually found to cover it. The internal layer of the blastoderm is 



NATURE AND ANATOMY. 707 

doubtless also displaced, but it is not isolated, and consequently its 
products are never found inside the tumor. Therefore, in instances 
where the dermoid patch occupies any of the mucous cavities, the 
neoplasm will always be found external to the mucous membrane. 
This theory serves to explain why these hairy tumors are found in 
the foetus, child, virgin, matron, or male, and with equal plausibility 
why they may exist in any part of the body. 

Dr. Pauly, in an excellent paper in the American Journal of 
Obstetrics, expresses a doubt whether the} 7 exist more frequently in 
the ovary than elsewhere, notwithstanding the generally received 
opinion that this is the case, and at present it cannot be asserted that 
they are not as common in the male as in the female. This theory 
would certainly not furnish us with reasons for their occurrence more 
frequently in woman than in man. 

If nothing unusual happens the adventitious sac grows with the 
individual in whom it is situated, and perhaps attains maturity as the 
same character of organs mature elsewhere. The sac itself continues 
to increase in size, because of the constant secretion of the glands of 
the dermic structure. Growth from this cause would probably be 
slow if the activity of the tegumentary glands were not preternatu- 
rally quickened by morbific causes. When situated in the ovary, 
however, the conditions naturally calculated to impart an impetus, 
exclusive of what is termed pathological states, exist. Hence in 
them they grow more rapidly and larger than in other places or 
organs. The fluctuation of nerve force, circulatory supply, and 
nutritional conditions which take place in the ovaries in consequence 
of the processes of menstruation, sexual excitement, and the varied 
states of generation, disturb the states of these otherwise nearly sta- 
tionary neoplasms. 

These reasons would lead us to expect the dermoids situated in the 
ovaries to become large and to grow more rapidly than in any other 
organ or locality. When situated in these bodies their progress is 
usually tardy until the age of puberty is reached. At this time the 
tumor is likely to be influenced by the increased nervous and vascular 
activity assumed by the ovary, and thenceforward they manifestly 
possess all the conditions necessary to cause copious dermic secretions. 
In the ovaries, also, their growth is more likely to be influenced by 
the morbid impressions to which these organs are more frequently 
subjected than almost any other part or organ of the body. They 
are also doubtless especially stimulated by the occurrence of the con- 
ditions which give rise to the colloid tumors. For in connection 
with this form of tumor they are generally found to have assumed 
great proportions. 

The conditions imparted to dermoid tumors by the ovaries would 
almost necessarily lead to their discovery during the lifetime of the 



708 OVARIAN TUMORS. 

patient, and thus favor the idea that they are more frequently located 
in these organs. Situated in organs of more unvarying functions 
they would be likely to remain dormant, and never attain dimensions 
that would cause them to be discovered ; consequently they are over- 
looked in the general statistics on the subject. 

After ovarian tumors have been developed to a certain extent 
they become subject to diseases and accidents, and thus play an im- 
portant part in the sanitary conditions of patients in whom they 
exist. Inflammation attacks them, and causes ulceration in their 
walls so as even to perforate them, making a communication between 
the cavities of contiguous cysts, or with the peritoneal cavity. With- 
out perforating the walls of the tumor, the ulceration may produce a 
good deal of pus, which is mingled with the other contents of the 
cyst in which it occurs. General inflammation of its walls may pro- 
ceed to a fatally exhaustive extent, or spread to the peritoneum, and 
thus indirectly cause death. Gangrene may also result, which may 
be confined to the cavity of some of the cysts, and induce a putrid, 
offensive state of the contents, or perforate the dividing partitions, 
and thus make a communication between cysts, or open them into the 
peritoneal cavity. The walls may also rupture from distension in 
consequence of their becoming attenuated, or as the effect of a violent 
stroke or fall, or other shock, and the contents escape into the perito- 
neal cavity. By means of ulcerative communication with the Fallo- 
pian tubes the fluid sometimes escapes. Adhesion to the walls of the 
abdomen from inflammation and ulceration through the parts thus 
agglomerated sometimes results, and the fluid so discharged. Inflam- 
mation also causes adhesion at various parts. The fibrin effused 
glues it to the surrounding parts, — the abdominal walls, the intestinal 
canal, bladder, and other viscera. Slight inflammation is supposed 
to increase the effusion in their cavities, and cause them to grow very 
rapidly. Inflammation, also, sometimes, no doubt, causes oblitera- 
tion of the cavity from adhesion of the walls. This is more frequently 
the case when it results from external causes, as blows, tapping, pres- 
sure, injection, etc. Now, it hardly ever happens that these diseased 
conditions and accidents of the tumors fail to produce their effects 
upon the health of the patient. No doubt but that death occurs from 
extensive disease in the sac, without any organ being directly involved. 
A large production of pus would exhaust the patient ; gangrene, to a 
large extent, would cause death, as extensive gangrene of unimportant 
organs generally does. But an extension of disease to the peritoneum 
and surrounding viscera, or by the effusion of the acrid contents of a 
diseased cyst, is more likely to be the mode of progress to constitu- 
tional disturbances inaugurated by inflammation in the tumors. 

When the tumor bursts, and its contents are effused into the peri- 
toneal cavity, the peritoneum seldom escapes without inflammation ; 



NATURE AND ANATOMY. 709 

but the degree will depend upon the nature of its contents. If they 
are not vitiated, but consist of the bland albuminous fluid found there 
ordinarily, it is very slight indeed, and lasts for a very short time only. 
But should pus, or the ichor of decomposition, be mingled with it, we 
should be prepared to expect serious if not fatal results. 

I once had an opportunity of observing the progress of a case for 
several months, where this rupture and effusion were frequently re- 
peated. About every three weeks the woman would attain to a large 
size, and a well-defined large cyst could be felt filling up the whole 
abdomen and distending it greatly, when suddenly, without premoni- 
tion or apparent cause, the cyst would give way, the swelling would 
become more diffuse, fluctuation more obvious, and the cyst could 
be no longer defined by the touch ; slight fever and some tenderness 
of the abdomen would last for two or three days, when copious per- 
spiration and diuresis would evacuate the fluid in a few days more. 
After this process was completed, the abdomen would be lank, and a 
small cyst could be felt rising up from the left ilium ; it would in- 
crease and burst at the end of three weeks, as the other had done before. 
I saw the patient frequently while this process was repeated six or 
seven times, when, as she would not submit to the operative proce- 
dure which I insisted upon, I was dismissed, and an irregular prac- 
titioner, who was sure he could cure her, installed in my place. Not 
long (perhaps three months) after I was discharged she died from the 
inflammation resulting from one of these effusions, probably because 
the contents of the cyst had become vitiated by inflammation. 

But these growths may produce a pathological condition of the 
system without becoming themselves the seat of disease, by the great 
size they may attain mechanically interfering with the functions of 
the pelvic and abdominal viscera. Before rising out of the pelvis it 
may displace the uterus, and cause inconvenience from this effect ; it 
may press upon and obstruct the rectum, bladder, and urethra, or 
upon the iliac veins, causing obstruction to the flow of blood, and 
varicose veins in the legs, phlebitis, or phlegmasia clolens ; or pressing 
upon the nerves, cause neuralgic pains in the limbs, hips, etc. It is 
plain that such pathological effects, when induced, would be serious, 
in proportion with the greater or less impaction in the pelvis by its 
continued growth. Ordinarily, these inconveniences do not prove 
very embarrassing to the functions of the important vital organs, but 
sometimes the case is far otherwise, and life is very much shortened 
and health rendered miserable. As it rises into the abdomen these 
mechanical troubles are apt to be lessened ; and as the room is com- 
paratively so great in that cavity, quite a while elapses before any 
great disturbance results from mechanical pressure. After awhile, 
however, the abdominal muscles are distended beyond convenient 
size, and the tumor is strongly pressed among the viscera. The kid- 



710 OVARIAN TUMORS. 

neys, liver, stomach, intestinal tube, in fact, all the abdominal organs, 
may become the subject of great and even fatal pressure. In many 
instances, however, enormous size is attained before fatal damage re- 
sults. One hundred and fifty pints of fluid have been taken at a single 
tapping. A much less amount, in most cases, would produce very 
grave results by pressure. When the growth is rapid, its mechanical 
effects will be more distressing; and, on the contrary, the organs 
accommodate themselves to a great deal more pressure if gradually 
brought about. 

Besides the inflammatory changes that take place in the tumor, 
chronic degeneration is occasionally observed. Deposits of earthy 
substances in the wails, bony spiculse, etc., are the most frequent. 
Small tumors, containing solid material, are more commonly thus 
affected. 

Modes of Termination. 

The modes of termination are worthy of some consideration. Man) 7- 
cases, in consequence of a low grade of vitality, last through a great 
many years without materially influencing the general health, and up 
to the death of the patient, at an advanced age, when large, prove to 
be nothing more than an inconvenient burden, and when small not 
the cause of even this kind of trouble. Others, in consequence of their 
bounteous vascular supply and energetic vitality, bring about fatal 
conditions of the abdominal organs in a few months. Spontaneously 
favorable terminations are so rare that we can base no calculation 
upon them. Perhaps rupture of the sac into the peritoneal cavity, col- 
lapse, and adhesion of its walls, is the most common and favorable 
spontaneous termination. After the rupture, in cases where cure fol- 
lows, it is probable that the opening in the sac continues, and as a 
permanent fistula from the cyst into the peritoneum, places the fluid 
in contact with a more active absorbing surface, until, by the elasticity 
of its walls, it contracts to annihilation, or, at the first shock of the 
rupture, inflammation is originated that causes an obliteration of the 
cavity of the sac. Dr. Simpson speaks of instances of evacuation 
through the vagina. The same thing might occur in connection with 
the bladder or alimentary canal. I have already spoken of adhesion 
to and rupture through the walls of the abdomen, and consequent 
recovery. Inflammation in its proper tissues, no doubt, sometimes 
arrests the development of and obliterates the tumor without mate- 
rially affecting the patient's general health. It is not improbable that 
other circumstances with which we are not acquainted may likewise 
operate to cause the arrest and cure of them, inasmuch as they unques- 
tionably do sometimes disappear in an unaccountable manner. 

The local pressure interfering with the functions of the bladder and 



TERMINATION. 711 

rectum may induce complicating diseases that lead to death, and con- 
sequently cause death before the tumor is very largely developed. 
Inflammation will spread upon these organs to their more vital con- 
nections and relative organs ; or, by interfering with excretion from 
the bowels or bladder, produce disease of the blood, and thus gradu- 
ally undermine the health of the patient. 

After the tumor has ascended into and greatly distended the ab- 
dominal cavity, pressure upon the viscera will sometimes produce 
disastrous terminations. The stomach is crowded into a very small 
space, food can be taken but sparingly, and is often rejected before 
digestion is completed. The vascular supply of this organ is cramped, 
and its secretions vitiated and embarrassed, and in this way digestion 
is interfered with, the appetite destroyed, and loathing of food takes 
its place. 

Pressure upon the vena porta embarrasses the secretion of the liver. 
Pressure upon the ductus choledochus, gall-bladder, and duodenum 
stops the excretion of bile; it is dammed back upon the gland, ab- 
sorbed, and thrown into the blood to poison the nervous centres. 

There is no doubt, also, that the general compression of the organs, 
by pressure upon the chyle absorbents, prevents that fluid from pass- 
ing as freely as usual into the blood, and thus by degrees starves the 
patient. But probably no more disastrous effects of the pressure of 
the tumor in the abdomen is noticed than such as is produced through 
the kidneys. Pressure upon the emulgent veins causes congestion of 
the kidney, retention of urea and other matters that should be excreted, 
and drains off the albumen with the urine, until the blood becomes 
thinned enough to infiltrate into the cellular tissue in the form of 
oedema of the extremities, or into the peritoneal cavity, giving rise to 
ascites. But this is not the worst mischief, perhaps, caused by the 
pressure on the kidneys. The poisoning of the blood with urea, and 
its effect on the nerves and vital organs, is too well known to require 
more than mere mention to suggest the rapidly fatal tendencies which 
result from it. 

Inflammation in any of the important abdominal organs may be 
caused by the pressure, which will terminate fatally in a greater or 
less time, owing to its acuteness or slowness of progress. It will be 
seen by the above that ovarian disease usually terminates by inducing 
a long train of distressing constitutional symptoms. They are not 
uniform, some persons suffering from one mode of complication and 
some from another; but nearly all are pretty sure to experience those 
terrible sufferings which are connected with secondary disturbances in 
the vital organs. 

The presence of the tumor, when not large enough to press upon 
the organs sufficiently to do very much damage, sometimes leads to 
copious dropsical effusion in the peritoneal cavity. This is, at least 



712 OVAKIAHf TUMORS. 

sometime?, the result of an influence exerted upon the peritoneum. 
causing it to secrete more than an ordinary amount of serum. 

One case upon which I operated and evacuated a large amount of 
serum from the perifoneal sac recovered completely from the opera- 
tion, but died about two months after from extreme abdominal dis- 
tension, in spite of alteratives and diuretics. 

Causes. 

It is extremely doubtful whether there is anything in the general 
condition of the patients that predisposes to the development of 

ovarian tumors. There is quite a disposition, however, with certain 
author-, as will be apparent to any careful reader, to trace most chronic 
enlargements to scrofulous taint in the system : and these gentlemen 
express the belief that scrofula predisposes to ovarian disease. I think 
we may very safely conclude that in the function of menstruation we 
have a predisposing cause of ovarian disease. It is true that ovarian 
tumors have been found in the ovaria of infants and foetuses, and very 
aged females : but this probably is as rare an exception to the general 
rule — that they occur during menstrual life — as the occurrence of men- 
struation in infancy and old age. Some circumstances connected with 
menstrual life appear also to increase the predisposition. Sixty-one 
per cent., according to Dr. West, of the patients were married, while 
only twenty-nine had never been married. After making allowances 
far the greater proportion of women at twenty-live who are married. 
I think that we may fairly infer that marriage adds somewhat to the 
chances oi the occurrence of ovarian dropsy. 

That patients who are the subjects of this disease should be less 
likely to have children than those in whom ovulation is more perfect 
and complete, will not. I think, justify us in setting down sterility as 
the cause of it in any way. but it is more probably connected as an 
effect. During menstrual life the most obnoxious time is between the 
ages of twenty-five and forty, the time when the sexual functions are 
-exercised with more activity than any other. 

Unhealthy menstruation seems to be more commonly coincident 
with it than healthy. Abortions and premature labor are so likewise. 

We should attach sufficient importance to the fact that it occurs in 
unmarried persons as often as twenty-nine percent. This induces Dr. 
West to remark, that " it occurs in the unmarried oftener than any 
other organic disease of the sexual organs." 

The exciting or proximate causes are such as excite the ovaria and 
induce abortive efforts at ovulation. What does so we are not able to 
say with certainty,* probably chronic inflammation. 

Inflammation of a low grade, and somewhat chronic duration. 

* >ee Chronic Ovaritis. 



PROGNOSIS. 713 

might cause induration or thickening of the indusium, so that it would 
not yield to the upheaving pressure of the ovisac and permit dehis- 
cence. 

The probabilities, I think, are in favor of this mode of merging a 
healthy into an unhealthy accumulation. When once thus commenced, 
the stimulus of increased incretion of fluid would carry on a kind of 
hypertrophy in the involucra that would permit of a further enlarge- 
ment. The local circumstances regarded as the causes of the disease 
would favor the occurrence of inflammation, and are very frequently 
attended with some of the symptoms of it. The ovary and uterus, 
during each menstrual period, are often attended with pain in the 
ovarian region of just such a character as we would expect to indicate 
inflammation. This ovarian pain is present in other excited con- 
ditions of the sexual organs also, thus showing that they are often 
the focus of painful vascular turgescence, if not inflammation. While 
inflammation is probably the cause of the beginning of the develop- 
ment of ovarian tumors, it does not seem necessary to their continued 
development, as the accumulation of fluid in a shut cavity, with a 
secreting internal surface, is a matter of course, and the limit of its 
amount, for the most part, does not depend upon anything but the 
capacity of the involucra to grow, until interrupted by external cir- 
cumstances. 

Although inflammation may, in most cases, be the cause of the 
toughness of the covering to the ovary, which prevents the escape of 
the ovum, this condition may result from some other local circumstance. 
Congenital formation may be such as to permit the involucra to in- 
crease as fast as the demand for more room becomes necessary. 

Prognosis. 

Our knowledge with regard to the prognosis is unfortunately too 
definite. There is no need of much conjecture with reference to this 
matter ; the termination is too frequently demonstrated. In arriving 
at prognosis with reference to any disease, we ought to consider 
whether its ordinary course is, after a time, to a termination in health, 
as is the case with many diseases, or, there being no such favorable 
tendency, what are the probabilities of a cure. Unfortunately, there 
is almost no tendency to spontaneous recovery in ovarian dropsy ; 
probably not two per cent, but would, after a longer or shorter time, 
terminate in the death of the patient. While this is the case, it does 
not properly represent the value of a life threatened by this affection. 
Some patients live a great many years in comparative comfort; but, 
by large odds, the case is generally very different, — only a few years 
being sufficient to finish the course in a downward direction. The 
average duration of life is about three years from the time it is first 
perceived. 



714 OVARIAN TUMORS. 

We should carefully examine every individual case with reference 
to its own peculiarities, its nature, and the character and condition of 
the patient. Is the disease simple, or a compound of cyst and solid, 
polycystic or monocystic? The monocystic is very much more favor- 
able for treatment, and terminates in spontaneous recovery oftener 
than the polycystic. The duration of life is greater, also, in the mono- 
cystic. If several years have elapsed since the patient was aware of 
the presence of the tumor, it will probably continue to increase slowly, 
unless, as is sometimes the case, more activity has lately been ob- 
served, so that a tumor that had formerly grown very slowly, and 
required a number of years to acquire half its size, has grown the rest 
in a few months. In this last, there is every probability of a rapidly 
fatal course. Again, if the patient has not known any increase of size 
until within a few months past, and yet is quite large, the prognosis 
is bad. Our prognosis is influenced by age to a considerable extent ; 
occurring in young persons, it is more likely to advance rapidly than 
in old ones. A woman at forty is not apt to develop an ovarian 
dropsy so rapidly as one at from sixteen to twenty. 

Ovarian dropsy will advance less rapidly after menstruation ceases 
than before, and the earlier in menstrual life the more rapidly it will 
advance. The prognosis, as a general thing, therefore, is worse in the 
young than the old. If we should decide the question by age how 
long will she live, we should speak more favorably to the woman 
advanced in years. 

The inflammation, the pressure upon the rectum, bladder, stomach, 
bow T els, and, above all, the kidneys, the nervous system, the vascular 
system, nutrition, as shown by the signs of emaciation or otherwise, 
should all be carefully scrutinized. 

Diagnosis. 

The diagnosis of ovarian tumors, when tolerably large, and not 
complicated with more than ordinarily embarrassing circumstances, 
is not difficult ; but instances do occur where the matter is far other- 
wise, and a positive opinion cannot, with propriety, be given. 

Remarks on Diagnosis of Ovarian Tumors Generally. 

The history will afford us in many cases, however, very valuable 
aid in arriving at correct conclusions. It is now pretty well deter- 
mined that the average duration is about three years. In this time 
it will spontaneously produce fatal effects, by great size and extreme 
distension, and the resulting damage. This is longer than pregnancy 
lasts, and a shorter time than is required for solid fibrous growths to 
reach the same results. The age at which they are most likely to 
occur is an average of twenty-six years, according to Mr. Brown, 



PHYSICAL EXAMINATION. 715 

although they may occur at any time during the active condition of 
the sexual functions, while the ovaria are subject to menstrual con- 
gestions and their effects. Quite a large number of cases make their 
first appearance in early menstrual life. In rare instances they are 
congenital and show themselves in infancy and childhood. Fibrous 
growths of the uterus are not likely to begin so soon. Their increase 
after being first observed is comparatively rapid, more so in the young 
than those somewhat advanced in age. They are not usually at- 
tended with pain in their own proper substance ; this is not always 
true, for the congestion and hyperexcitement may be attended with 
pain and soreness. Functional disturbances in their early stages often 
occur in the pelvic viscera; first, on account of pressure, such as 
tenesmus, dysuria, dragging, or weight in the pelvis ; and secondly, 
imperfect menstruation. Sometimes the menses are suppressed, scanty, 
and painful, but often no deviation is observed. The main thing in 
the history of the case, in this respect, is to remember that the symp- 
toms point in the beginning to trouble in the pelvis. It is generally, 
or at least sometimes, stated that the tumor rises from one iliac region 
and continues to occupy one side for some time. This, I think, is 
the exception to the rule, and, by Dr. Frederick Bird, is considered 
an evidence of adhesion. When large enough to overcome the sup- 
port of their peritoneal envelope, they fall into the cul-de-sac of 
Douglas, and, as they grow, come up in front of the promontory of 
the sacrum, until large enough to be felt above the pubis, having 
their point of support in the hollow of the sacrum, instead of one of 
the iliac fossae. The patient will usually speak of it as a lump, in- 
stead of saying that she is swollen, as in pregnancy. She has watched 
it coming up out of the pelvis, and not starting from above or from 
one side, and encroaching upon the abdomen from either of those 
directions. 

Physical Examination. 

The knowledge derived by physical examination is the most valu- 
able ; and while the modes of procedure are the same, and applicable 
to all stages of growth and enlargements of the tumor, we will be able 
better to describe and understand them, as made use of for one that 
has arisen from the pelvis, and more or less thoroughly filled the 
abdominal cavity, — a tumor that has become obvious, and from which 
our patient is solicitous of being relieved. 

The means afforded us for physical examination are : 1st, palpa- 
tion ; 2d, percussion ; 3d, auscultation ; 4th, vaginal and rectal digital 
examination; 5th, examination with the sound or uterine probe. 
These may be used separately, or combined in any given case ; some 
being more valuable in some cases, and others in different ones. 
Exploring needles, chemical tests, and the microscope may also be 



716 OVARIAN TUMORS. 

used to great advantage. Palpation is of very little use while the 
tumor is still in the pelvis, except in conjunction with the vaginal 
touch or the uterine probe ; as it rises in the abdomen, however, this 
process of examination comes into use independently. In this con- 
dition we can examine the consistence, size, shape, and mobility of 
the growth, and form some opinion as to its adhesion to the walls of 
the abdomen, and its primary attachments. 

Palpation and Percussion. 

In the ordinary condition of the contents of the abdomen the in- 
testines lie in contact with the anterior and lateral walls, except in 
the right and left hypochondria, where the liver, over a considerable 
space, and the spleen, a smaller, displace them. In consequence of 
this state of things, the resonance caused by the gas in the alimentary 
tube extends all over the anterior and lateral walls, save the above 
exceptions. Dulness upon percussion, therefore, indicates the presence 
of a tumor. The mesenteric attachments between the posterior wall 
of the abdomen and intestinal tube prevent them from being separated 
from the spine to any considerable extent ; hence tumors occupying 
much space are apt to displace and get anterior to the latter. If the 
tumor springs from the pelvis this is particularly the case, as well from 
the above facts as the direction given to it by the axis of the superior 
strait ; thus it is with the gravid uterus, uterine fibrous growths, and 
ovarian enlargements. Growths from the pelvis, perhaps, more com- 
pletely gain the anterior position than any other sort, unless it be such 
as are attached to the anterior wall originally. It may be observed, 
too, that it takes a larger growth to disengage itself from intestinal 
resonance when arising from the posterior wall than from any other 
situation in that cavity. 

By percussion we may make out the boundaries, positions, and, to 
some extent, attachment and contents of an abdominal tumor. We 
should begin at the pubis, and follow a line upward to the ensiform 
cartilage ; by so doing we will ascertain the central perpendicular 
extent. A good plan is to make four or five perpendicular explora- 
tions of this kind each side of the median line, extending the whole 
length of the abdominal cavity. After this has been done we may 
proceed, by right angles to these lines, to examine the abdomen cross- 
wise, from its lower to its upper boundary. We will seldom miss any 
important growth by this mode of proceeding. If there is any doubt 
or obscurity, pressure in connection with percussion should be suffi- 
cient to bring out something of the flatness of sound from the spine, 
kidneys, etc. If we discover any point of sufficiently defined dulness 
to impress us with the idea of a tumor, we should, by percussing ex- 
plorations, proceed from the point of greatest dulness to its circumfer- 



PALPATION AND PERCUSSION. 717 

ence in every direction. In this way of examining, we will be able to 
trace it up the side to the hypochondriac regions down into the pelvis, 
or define it so perfectly as to decide what must be its place of origin. 
Another valuable method of employing palpation is to place one hand 
on each side of the abdomen, and press them strongly toward each other. 
If there is a tumor its resistance to their approximation will demonstrate 
its presence. Percussion and palpation Will often enable us to deter- 
mine the contents of a tumor as to its solidity or fluidity. Placing 
the finger on one side of the tumor, while we percuss the other, if the 
contents are wholly fluid, a wave of liquid will be set in motion on 
the side struck, and traverse the space to the one of the opposite ; if 
solid, of course nothing of this kind will take place, and the impulse 
will be given to the whole substance of the growth. Should the 
contents be fluid, separated by a number of partitions, the wave or 
fluctuation will be less distinct than in the one where no such division 
exists ; but in fact the obscurity is so great that we will be at a loss 
by this management to decide whether the contents are solid or fluid. 
A slight variation of this combination of tact and percussion will 
often clear it up, however. When we wish to ascertain whether the 
fluid is contained in several cysts, we should place the pulp of the 
fingers of the left hand in the centre of the tumor, and then percuss 
with those of the right, first very near, then gradually increase the 
distance between them, until we find a point at which the fluctuation 
becomes less distinct ; this is the margin of the cyst over which our 
left fingers are placed. Still keeping them in position, we percuss 
around in every direction, until we have made out the boundary and 
size of the cyst under examination, when we may move the fixed 
fingers to its margin, and commence the same process around this 
point. Proceeding in this way from one point in the abdomen to 
another, in most instances we may trace the outline of all the cysts 
superficially situated, and thus enumerate them, and learn their rela- 
tion and absolute size. If solid bodies, of whatever structure, are 
incorporated in the mass and superficially situated, they may be de- 
tected with their relative position, size, etc. 

After tapping, when the abdomen is lessened, its walls lax and 
soft, palpation, and percussion, singly or combined, become more 
demonstrative than before this operation. It not unfrequently is 
necessary, on account of the sensitiveness of the patient, when the 
tumor is small, and the abdominal muscles not much under control 
of the will, to administer an anaesthetic until unconsciousness is in- 
duced, and the influence should often be so profound as to abolish 
reflex sensibility. Palpation and percussion should both be practiced 
ordinarily with the patient in the recumbent position on the back, 
with knees drawn up, shoulders elevated, and the abdomen stripped 
quite bare of covering ; in many instances, however, variation of post- 



718 OVARIAN TUMORS. 

ure is indispensable to definite results, — the standing, prone, etc. 
Very little need be said in this place about auscultation, as it is only 
applicable to the diagnosis between it and pregnancy, and will be 
dwelt upon when I come to speak of that more particularly. Vaginal 
and rectal digital examinations in ovarian disease are proper, and 
should not be dispensed with. The pelvis should be carefully sur- 
veyed by this method. The attachments, consistence, and relations 
of the diseased mass to the various organs in this cavity should be 
carefully noted. The uterus, rectum, and bladder, so far as practica- 
ble, ought to be examined with reference to their healthy condition, 
position, and involvement. Combined with external palpation, we 
may examine the tumor more thoroughly than with either one alone. 
Two fingers introduced into the vagina, and pressed firmly upward 
against it, will perceive any impulse imparted to the tumor above. 
With the left hand, if we press downward toward the pelvis, we may 
feel the motion of the diseased accumulation downward, and, if the 
sudden impulse of percussion is applied above, we may feel an impres- 
sion from its contents ; if fluid, a wave or sense of fluctuation ; if solid, 
the deadened impulse always given in such cases. When the tumor 
is small, and occupies the posterior peritoneal cul-de-sac, by intro- 
ducing one finger in the rectum and the other into the vagina, the 
tumor rnajr be included between them, and thus examined with more 
accuracy than with either alone. 

The late Sir James Y. Simpson taught us how to extend our exami- 
nations into the uterus, so that our information in this direction is 
very materially increased by the use of the probe mounted upon a 
handle. Members of the profession who appreciate the labors of Dr. 
Simpson have, by consent, named the instrument, the improvements 
and uses of which he has so ably promulgated, " Simpson's sound." 

The sound may be introduced into the uterus, and varied in its 
direction, while we gently urge it forward to the extremity of the 
uterine cavity. The only obstacle a sound of the proper size will 
meet with in a uterus of ordinary size arises from want of correspond- 
ence with the direction of the cavity. The most simple and ready 
revelation of the sound or probe is the direction and length of the 
uterine cavity. From this knowledge much valuable deduction may 
be drawn. But it is employed for determining the relation of the 
uterus to pelvic tumors, according to the ingenious directions of Dr. 
Simpson, very handily and to excellent purpose. While the sound 
is in the cavity of the uterus, this organ may be fixed by holding the 
instrument firmly in one position, or be moved in any direction, if not 
restrained by adhesion or accretional attachment to the diseased mass, 
or to some other organ. If the uterus be fixed, and the tumor moved 
by its side or from it, with the fingers introduced for the purpose, the 
motion will be felt affecting the uterus through the attachments. On 



EXPLORATION. 



719 



the other hand, if we watch the motion of the tumor with the fingers 
while the uterus is moved, the attachment or not will be determined, 
or the uterus may be moved in one direction and the tumor in another. 
In this way their attachments may be pretty certainly diagnosticated. 
The sound may be employed in the uterus with one hand, while pal- 
pation on the abdominal surface is effected with the other ; and, if the 
uterus reaches above the pubis, the distance the probe is separated 
from the external hand, or its relation with the median line of the 
abdomen, or the main bulk of the growth, will enable us to determine 



Fig. 297. 




<M CODMAN &, SHURTLEFF, 
BOSTON. 

Aspirator. 



some interesting problems. The motion received by the sound from 
the pressure of the hand without, or vice versa, is of important signifi- 
cance, as will be more apparent as we advance. 



Exploration. 

When, from all these sources of inquiry, we fail to get a sufficiently 
definite answer, there is still another physical means of diagnosis 
which we are justified in employing, viz., exploration. By means of 
an exploring needle, or aspirator, we can draw off a small quantity of 
fluid, which may be subjected to microscopic and chemical tests that 
will often enable us to determine the nature of the disease. 

Dr. J. Hughes Bennett, in a paper on " Ovarian Disease," in the 
Edinburgh Medical and Surgical Journal, quoted by Mr. Brown, says, as 
the result of his microscopic " examinations of different specimens of 
ovarian fluid, that the most constant characteristic of such fluid is its 
containing, in greater or less abundance, cells gorged with granules ; 
and, in addition, circumambient granules, having the same measure- 
ment as those encompassed by the cell- wall. At one time I considered 
the size of these granules (if they can properlv be so called), was con- 



720 OVARIAN TUMORS. 

stant, but subsequent observations have convinced me of the incor- 
rectness of this conclusion ; the size of the gorged cells and granules 
varies greatly, even in the fluids from different cysts of the same 
ovary." There can be no question but that the nature of the fluid 
contained in these cysts is. in all its essential features, pretty con- 
stantly the same in the early stages of progress ; but it is equally true 
that, as they grow large enough to be influenced by pressure or other 
external causes, their microscopic composition must vary. 

Although my opportunities for microscopic examination of ovarian 
fluid have been quite limited as compared to others, I cannot but 
express a decided belief in the conclusion arrived at by Dr. T. M. 
Drysdale. 

I have never found the ovarian cell described by Drysdale in any 
but ovarian fluid ; nor have I failed to find it in specimens that I 
knew to be fluid from an ovarian tumor. It is but fair to say. how- 
ever, so many of the best gynecologists doubt the accuracy of his 
conclusions, that the question is far from being settled. 

The fluid drawn from the tumor is generally turbid and discolored, 
often chocolate color. When felt between the thumb and finger it is 
sticky, and sometimes very tenacious and ropy. 

The granular cell revealed by the microscope, according to Drys- 
dale, is best exhibited in contrast with other pathological products 
contained in the sac, as given in the plate and description on pages 
458-59 of Ovarian Tumors, by Dr. W. L. Atlee. 

11 On the Granular Cell jo and in Ovarian Fluid. 

" On placing a drop of the fluid removed from an ovarian cyst under 
the microscope, we usually find (Fig. 298) a number of granular 
cells, e, some free granular matter, c, and small oil-globules, b ; and 
frequently, in addition to these, epithelial cells of various forms, a, 
and crystals of cholesterin, d. These, together with blood-corpuscles, 
f, the inflammatory globules of Gluge, i, the pus-cell, g h, and disin- 
tegrated blood and other cells, may all be sometimes seen floating in 
either a clear or a turbid fluid. 

' ; To find them all present in one specimen, however, is rare ; more 
commonly we can discover but three or four of them in the fluid. 
But no matter what other cells may be 'present or absent, the cell which is 
almost invariably found in these fluids is the granular cell. 

" This granular cell, e, in ovarian fluid is generally round, but 
sometimes a little oval in form, is very delicate, transparent, and 
contains a number of fine granules, but no nucleus. The granules 
have a clear, well-defined outline. These cells differ greatly in size, 
but the structure is always the same. They may be seen as small as 
the one five-thousandth of an inch in diameter, and from this to the 



THE OVARIAN CELL. 721 

one two-thousandth of an inch. In some instances I have found 
them much larger, but the size most commonly met with is about that 
of a pus-cell* (Fig. 298.) 

" The addition of acetic acid causes the granules to become more 
distinct, while the cell becomes more transparent. When ether is 
added, the granules become nearly transparent, but the appearance 
of the cell is not changed. 

" This granular cell may be distinguished from the pus-cell, lymph- 
corpuscle, white blood-cell, and other cells which resemble them, 
both by the appearance of the cell and by its behavior with acetic 
acid. 

" The pus and other cells, g, which have just been named, have 
often a distinctly granular appearance; but the granules are not so 
clearly defined as in the granular cell found in ovarian disease, owing 
to the partial opacity of these cells; and, when the granular cell of 
ovarian disease and the pus-cell are placed together under the micro- 
scope, this difference is very apparent. In addition to the opacity 
of these cells, we frequently find their cell-wall appearing wrinkled 
rather than granular ; and further, in the fresh state, they are often 
seen to contain a body resembling a nucleus. 

" But if there is doubt as to the nature of the cell, the addition of 
acetic acid dispels it ; for if it is a pus-cell, or any of the cells named 
above, it will, on adding this acid, be seen to increase in size, become 
very transparent, and nuclei, varying in number from one to four, 
will become visible. (See g, pus-cell, before adding acid ; and h, pus- 
cell, after adding acid.) Should the cell, however, be an ovarian 
granular cell, the addition of this acid will merely increase its trans- 
parency and show the granules more distinctly. 

"The compound granular cell, I, the granule cell of Pagetand others, 
or inflammation-corpuscle of Gluge, is also occasionally present in 
these fluids, and might possibly be mistaken for the ovarian granular 
cell ; but it is not difficult to distinguish them from each other. Gluge's 
cell is usually much larger and more opaque than the ovarian cell, 
and has the appearance of an aggregation of minute oil-globules, some- 
times inclosed in a cell-wall, and at others deficient in this respect. 
The granules are coarser, and vary in size, while the granules of the 
ovarian cell are more uniform and very small. By comparing them 
in the drawing, these differences will be apparent. Again the behavior 
of these cells on the addition of ether will at once decide the ques- 
tion ; for while the ovarian granular cell remains nearly unaffected by 



* " By comparing the drawing of the ovarian cell which accompanies this paper 
with one given in Dr. Atlee's work on Ovarian Tumors, it will be seen that I have 
omitted the three large dark cells which form the left of the group representing the 
ovarian cell in that drawing, and which are inaccurate." 

46 



'22 



OVARIAN TUMORS. 



it, or, at most, has its granules made paler, the cell of Gluge loses its 
granular appearance, and sometimes entirely disappears through the 
solution of its contents by the ether. 

" That the discovery of a granular cell in ovarian fluid is new I do 
not assert, as J. Hughes Bennett and other writers have described 
granular cells which they have seen in these fluids ; but, with one ex- 
ception, their description does not correspond with the ovarian granu- 
lar cell. Bennett, for instance (Ed. Med. and Surg. Journ., vol. lxv, p. 
280, 1846), states that the granular cell which he saw exhibited a dis- 
tinct nucleus on the addition of acetic acid, which is not the case with 
this. Other writers have described the cells which they found as pus 




Microscopic Examination of Fluid from Ovarian Tumors. 

and pyoid cells, and yet others confound them with the compound 
granular cell or inflammation globules. The exception referred to 
above is found in Beale's description of the microscopic appearance 
of ovarian fluid* He observes : 

"'The cells are composed of at least two distinct forms: 1. Small, delicate, trans- 
parent, and faintly granular cells, without the slightest appearance of a nucleus, some 
being somewhat larger, and others smaller, than a pus-corpuscle. 2. Large cells, often 



* The Microscope in its Application to Practical Medicine. By Lionel S. Beale, 
M.D., F.R.S., etc. 3d edit., p. 179. 



DIFFERENTIAL DIAGNOSIS. 723 

as much as the thousandth of an inch in diameter, but varying in size, of a dark color 
by transmitted, and white by reflected light. These, which have been termed "granu- 
lar corpuscles," " compound granular cells," "inflammation globules," etc., are aggre- 
gations of minute oil-globules in a cell form.' 

" It will be seen by this extract that Beale distinguishes the ' small, 
delicate, transparent, and faintly granular cells' from the compound 
granule-cells or corpuscles of Gluge. The description which he gives 
of the first cell, with the exception of the cell being faintly granular, 
corresponds very closely with that of the ovarian cell, but it is incom- 
plete, and no test is given to distinguish this from other granular 
cells."* 

I do not think he mentions with as much distinctness and empha- 
sis as it deserves the abundant, free, granular matter floating about 
in connection with the cells. In my observations this granular ma- 
terial, having the precise appearance of the granules in the cells, was 
the most striking of the microscopic appearances. 

The chemical nature of this fluid is more constant. It is alkaline 
in reaction and highly albuminous, always coagulating when boiled 
or submitted to the action of strong acids. 

Differential Diagnosis. 

After having passed in review, as above, the items of general diag- 
nosis of ovarian tumors, I propose to enter upon a differential view 
of the subject, because there are conditions of disease and health of 
the contents of the female pelvis and abdomen for which they may 
be mistaken. The following long list of conditions may be given 
as likely to be mistaken for ovarian tumor: 1st. Retroversion and 
retroflexion. 2d. Tumors of the uterus, — solid, fibrous, or fibro- 
cystic. 3d. Pregnancy. 4th. Pregnancy complicating ovarian clrops}^. 
5th. Cystic tumors of the abdomen. 6th. Distended bladder. 7th. 
Accumulation of gas in the intestines. 8th. Accumulation of faeces in 
the intestines. 9th. Enlargement of the liver, spleen, or kidneys, or 
tumors connected with the viscera. 10th. Rectovaginal hernia and 
displacement of the ovary. 11th. Pelvic abscess. 12th. Retention of 
menstrual fluid from imperforate hymen or closure of the os uteri. 
13th. Hydrometra. 14th. Accumulation of fat in the abdominal 
walls. 15th. Accretions in the subperitoneal connective tissue, or in 
the peritoneal cavity. 

Iii cases of retroversion or retroflexion, if minute examination with 
the finger per vaginam and rectum fail, and the symptoms are of a 
character to make a correct diagnosis important, the uterine probe 

* Thomas M. Drysdale, M.D., Philadelphia, in the Transactions of the American 
Medical Association, 1873. 



724 OVARIAN TUMORS. 

will at once determine the distinction. In some instances we might 
be quite unable to distinguish a small ovarian tumor from an impreg- 
nated retroverted uterus. Our proper plan in such cases is to await 
the peremptory demand for the knowledge, and then take the risk of 
introducing the probe, remembering the position of the mouth of the 
womb in retroversion, that it is not only near the pubis, but directed 
upwards as well as forwards, and that the os. in cases of misplace- 
ment by the tumor, is not directed upward, but nearly always down- 
ward, — certainly never, so far as my experience and reading go, 
above the horizontal position. The probe may be equally available 
in examining the retroflexed organ, and I think the probe should 
always be used where pregnancy is not suspected. Should we feel 
much doubt of the existence of pregnancy in connection with retro- 
version, it would be better to lift the tumor out of the pelvis ; when, 
if it were retroversion, the uterus would be restored to its natural 
position, with the os near the centre of the pelvis. In endeavoring 
to distinguish between ovarian and uterine tumors, we should bear 
in mind that the latter almost invariably change the length and size 
of the cavity of the uterus. Where the sound is used, it will pass 
further than if the uterus was not involved. The rationale of this 
increase of size of the uterus, so generally found to be present, is con- 
nected with the fact that the development of a tumor in or from the 
walls of that organ induces general hypertrophy to some extent, as 
these growths are found to be a hypertrophy of some one of the 
uterine tissues. The tissues generally involved are the fibrous or 
mucous, as in hard or soft polypi from the internal, or hard from 
the external walls, or intramural fibrous tumors. Uterine tumors 
are so intimately connected with the uterus that this organ cannot be 
moved without imparting more or less motion to the tumor, nor can 
the tumor, on the other hand, be moved without, in a similar way, 
affecting that organ. This is not the case with ovarian tumors. 
They are so loosely connected with the womb that considerable 
motion is allowable without the other partaking of it. In the sound 
we have the means of moving or fixing the uterus, and with the 
finger may watch the effect of motion upon the one or the other, as 
the case maybe. When the fibro-cystic tumor is developed upon the 
uterus, containing fluid, the examination to ascertain whether there is 
an attachment with the uterus, and with a view to learn the length 
of the cavity, will give us clear notions of the matter. When we are 
satisfied that pregnancy cannot be the condition, we may exjjlore or 
tap it as an additional means of accuracy. 

Hard or fluid tumors arising from a distant organ or part of the 
abdomen would have a different history from the ovarian tumor. If 
our patient is intelligent, her observation as to the place where first 



DIFFERENTIAL DIAGNOSIS. 725 

noticed should be relied upon as valuable knowledge respecting the 
probable point of origin. 

Ascites, when excessive, may sometimes be mistaken for ovarian 
tumor, but the latter is more frequently taken for the former. When 
the patient lies on her back, with the knees drawn up, so as much as 
possible to relax the muscles, and the abdomen is entirely exposed, in 
ascites the tumidity will be rotund, rilling out in every direction, and 
will particularly bulge the depending portions. The flanks will both 
be full; the abdominal protrusion commences at the edges of the 
ribs, and will be equally soft at every point; fluctuation will be 
greatest at the most dependent parts, and resonance entirely absent; 
fluctuation will scarcely be perceptible in the highest part of the ab- 
domen, but there will be resonance there. These circumstances will 
remain the same under any change of position. If the patient stand 
up the dulness is in the hypogastric and iliac regions. If she lie on 
her side, the dulness and fluctuation on the lower side ; resonance on 
the upper side. All this results from the water freely settling into 
the lowest points, let them be what they may. In ovarian tumor, 
alteration of position from erect to recumbent, or from supine to 
prone, makes no difference in the places where resonance and fluctua- 
tion are found. They are manifested always in the same places. 
When the patient lies on the back, the flanks are resonant, the um- 
bilical region dull. Fluctuation is not observed in the flank in any 
position; it 1 is apt to be greatest under any posture in the middle of 
the abdomen. When the abdomen is exposed for inspection there is 
marked irregularity in its rotundity, and I think, ordinarily, the flanks, 
one or both, are flat. One side is apt to bulge more than the other. 
Probably there is more than one rather prominent region, — it may be 
several. There is more hardness and tension ; not the flabby swaying 
under slight influences, so common as ascites. Important circum- 
stances in the pathological condition are almost always present in 
ascites. It seldom occurs in persons in the enjoyment of good health 
in every other respect. There is organic disease of the kidneys, liver, 
spleen, heart, lungs, or subacute peritonitis. Or there may be some 
cachexia from miasma, poison, or other bad influence of particular 
places of residence, occupation, habits or time of life, etc. There is 
some notable and grave pathological accompaniment of abdominal 
dropsy which precedes the swelling ; whereas the ill-health in ovarian 
dropsy is the effect and not the cause. We generally find that women 
preserve a good condition of health in ovarian disease until far ad- 
vanced, and disordered functions come almost always as the result of 
great pressure upon the suffering organ. A- complication of ascites 
with ovarian dropsy obscures our diagnosis very much. If the ascites 
is great, and the ovarian disease not so considerable, the tumor will be 
felt floating about, as it were, in the abundant fluid, when the patient 



726 OVARIAN TUMORS. 

changes position. Excluding by our diagnostic examination every 
other disease, and leaving the question between them alone, we are 
justified in exploration and tapping. By the former, we come in pos- 
session of a specimen fluid, which, when submitted to chemical and 
microscopical investigation, is almost conclusive. By the latter, we 
partially empty the abdominal cavity and relax the walls so that we 
can examine its contents with great freedom. If the fluid be ovarian, 
it will be highly albuminous, and possess the microscopical qualities I 
have before mentioned. If it be ascitic, the properties will be those of 
serum found exuded anywhere from pressure or inflammation. There 
w T ill be very little, if any, albumen, no epithelial cells, and none of the 
corpuscles described by Drysdale. 

It will occur very seldom that the question between pregnancy and 
ovarian disease will become so urgent that it may not safely be left to 
time. I can conceive no time or circumstance under which great doubt 
as to which of these two conditions were present but in the early stages 
of either, while in the pelvic cavhy ; and unless great pressure on the 
organs contained in it make delay hazardous, we should not interfere, 
but content ourselves to wait until the obvious evidences, as quicken- 
ing and motions of the child, declare the existence of pregnancy, or 
until so much time has elapsed without any such signs as to throw 
great doubt upon the subject. At such times the tumor is high above 
the pelvis, and may be subjected to any searching examination we 
may choose. Auscultation then becomes valuable and perfectly re- 
liable, when properly practiced, in determining the presence of normal 
pregnancy. 

Frequent examinations with the stethoscope or ear, in various posi- 
tions, should be patiently and perseveringly practiced before we should 
be satisfied to risk means of a hazardous nature that will enable us 
positively to decide the question. After having repeatedly thus ex- 
plored the abdomen without any sign of a live foetus, we may use the 
probe to examine the whereabouts and size of the uterus. No mistake 
will survive the test of this instrument. If I were not to explain 
myself a little more upon this point, I might incur the charge of rash- 
ness for recommending the sound where any doubts exist. It would 
be rash to use the sound until all the differential signs of pregnancy 
had failed, and even then, unless the urgent demand caused by the 
influence upon the health forbids us to wait longer for a decision. It 
is only in extreme cases, where the symptoms and signs derived from 
the breasts, condition of the cervix, menstruation, nausea, pigmentary 
deposits, and auscultation, had all failed, and yet I was obliged to act 
at once for the safety of the patient, that I should consent to use the 
sound. Then I would use it as the more innocent of the demonstra- 
tive tests, and as a dernier ressort. It is certainly more innocent than 
the exploring needle or the evacuating trocar, and equally demonstra- 



DIFFERENTIAL DIAGNOSIS. 727 

tive. The worst effects its careful use could have would be to produce 
abortion or premature birth, either of which would be more likely to 
remove the urgency of the symptoms than do harm. I have recently 
seen an instance of the obscurity of diagnosis, from the existence of 
a pregnancy of eight and a half months' duration, decided by the 
probe, which caused the discharge of a mummified foetus of less than 
four months' growth, and, as a matter of course, almost cured the 
patient. 

Pregnancy complicated with ovarian dropsy, may be very perplex- 
ing to diagnosticate. Mistakes of diagnosis have occurred in the 
hands of Sims, Wells, the author, and others. A careful examination 
of the cervix uteri, the abdomen, breasts, etc., for the evidence of preg- 
nancy above mentioned, will seldom fail to make a diagnosis of this 
complication clear. There are very few collections or growths that can 
be, in such conditions, mistaken for this. 

In pelvic abscess, there will be inflammatory tenderness and heat. 
The most likely of all others, is a prolapsed bladder. Our diagnosis, 
however, will be easily effected by using the catheter, when, if it is 
the bladder, emptying causes its collapse and the entire disappear- 
ance of the tumor. But if, after the complete evacuation of the 
bladder, there is yet a tumor containing fluid, exploration should be 
resorted to. This will clear up the diagnosis, provided the exploring 
trocar is large enough to evacuate a part or the whole of its contents. 
There are other fluid tumors, arising from the broad ligaments near 
the ovary, probably dependent upon a great increase of one or more 
of those transparent cells of serum, so generally seen by looking 
through this peritoneal duplicature, towards the light. These may be 
mistaken for actual ovarian cysts, and are doubtless the cases of 
ovarian disease that are permanently cured by a single tapping. No 
means of diagnosis now known would enable us to decide, with any 
certainty, between the two except chemical and microscopic exam- 
ination of the fluid. The fluid is a limpid serum of very low specific 
gravity, sometimes not above that of distilled water, often not more 
than 1004, not coagulable by heat and devoid of any microscopic 
peculiarity. It has a remarkable semblance in most of its qualities 
to pure water. Cystic tumors of the abdomen, arising from other 
points, and hydatids of the peritoneal cavity, can be distinguished 
with certainty in no way except by exploration and examination of 
the contents. The history will, if carefully and intelligently detailed, 
show something, perhaps, that we may seize upon to aid us. The 
case should commence, if ovarian, in a tumor arising from the pelvis, 
gradually ascending into the abdomen. If abdominal, it is first 
noticed in that cavity, and may descend until it occupies all the ab- 
domen, and then the pelvis also. If hydatid, the increase is mere 
tumidity, not a well-defined tumor, and it commences in the abdomen. 



728 OVARIAN TUMORS. 

The distended bladder, accumulation of gas in the intestines, or 
of feces, ought not. in the present state of our science, to embarrass 
us any longer than the catheter or a cathartic could be brought to 
bear upon the case. As soon as the bladder is emptied it will col- 
lapse. The gas in the bowels causes tympanites of the abdomen, 
and thus ought to be detected. The accumulation of faeces can be 
removed, when the tumor will be gone. Hysterical distension of the 
abdomen, said to simulate pregnancy, ovarian, uterine, and other 
tumors, entirely disappears under the influence of chloroform, as 
shown by Professor Simpson, on many occasions. 

Visceral enlargement, as liver, spleen, kidneys, and tumors growing 
from them, are not unfrequently mistaken for these tumors. I have 
a patient now laboring under enlargement of the spleen, who has 
been told more than once, that she had ovarian disease. Unless 
the enlargement of the liver or spleen is excessive. I cannot see how 
a mistake can be possible. The history as to where the tumor was 
first observed should be carefully traced. If either of these, it has 
descended. I have not seen a liver or spleen occupying the cavity of 
the abdomen so completely, but that its well-defined edge could be 
felt for a considerable distance, and this edge is always below, while 
the upper boundary is less defined or traceable beneath the ribs. I 
have on several occasions, seen the spleen enlarged and dislocated, 
occupying the left iliac region, and reaching up towards the hypo- 
chondriac, but there are always sharp edges somewhere. This is not 
the case in ovarian dropsy; it is round, somewhat even, and elastic 
to the touch. 

The liver is also sometimes displaced to such an extent as to rest 
upon the pelvic brim ; and, when enlarged, it may occupy an exten- 
di ve space in the abdomen. The three important points to be made 
in the differential diagnosis between displacements and enlargement 
of the liver and spleen and ovarian tumors are : 1st. they are flat in 
front, instead of globular: 2d. by somewhat forcible percussion even 
very decided intestinal resonance may be heard through them ; 3d, 
by well-directed manipulation in the horizontal position the displaced 
organ may be partially or completely returned to its natural nidus. 

Mr. Brown mentions recto-vaginal hernia and dislocation of the 
ovary into the cul-de-sac of Douglas. The diagnosis would be diffi- 
cult and unimportant unless in exceptional cases. The great impor- 
tance of a correct diagnosis is based upon the urgent symptoms and 
fatal tendency of the disease. 

Retention of menstrual fluid from imperforate hymen (or other 
obstruction to its outlet;, also hydrometra. as soon as we have by 
physical examination, history, and the rational symptoms, decided 
that the patient is not pregnant, the finger and sound will clear up all 



DIFFERENTIAL DIAGNOSIS. 729 

doubts in a short time. Obstructions will be ascertained or overcome 
by them, and our misgiving dispelled. 

Acute, and sometimes even subacute, inflammation of the peri- 
toneum is occasionally accompanied and succeeded by hard, fibrinous 
deposits of various sizes and location in the abdomen. When in the 
iliac and hypogastric regions they may be mistaken for tumors. They 
are flat, immovable, sensitive ; yield resonance in a very decided man- 
ner upon percussion, and date their existence from an attack, more or 
less remote, of peritoneal inflammation. 

Supposing our diagnosis complete as to its being an ovarian tumor, 
we have yet to learn, for the more intelligent treatment, several other 
things ; among these are : What are the contents and construction of 
it? Is it monocystic or polycystic? Are its contents parti} 7 solid, or 
wholly fluid? Although, probably, not always possible to decide 
these questions without exploratory operations, we have some means 
of clearing them up. A diligent and careful examination by percus- 
sion and inspection will enable us to judge correctly, in most cases, 
whether the tumor is monocystic or polycystic, or otherwise. If mono- 
cystic, the tumor is regular in its rotundity and outline ; if polycystic, 
there is some irregularity of elevation, made out best by sliding the 
hand over the surface. Fluctuation, caused by percussion, is the same 
in all directions and from all points of it in monocystic. In poly- 
cystic it is very obscure, except over partial measurements. The 
fingers placed near each other over the same cyst feel the fluctuation 
very sensibly ; but when one is removed so as to pass over the parti- 
tion between it and the next cyst, the fluctuation becomes more ob- 
scure. By examining all parts with both hands, separating and 
approximating each other, we make out the dimensions and situation 
of the cyst, which lies in contact with the abdominal walls. The 
fluctuation, or its absence, will determine whether a given part of the 
tumor is solid or fluid. The hard parts of an ovarian tumor are, 
almost invariably, at the bottom of the tumor, and may be reached 
by the finger per vaginam. While our fingers are in contact with the 
base of the tumor in the pelvis, if it is wholly fluid, we may feel fluc- 
tuation, if the top of the tumor is struck with the other hand. If a 
solid part intervenes between our two hands, fluctuation would not be 
experienced. 



CHAPTER XLIII. 

OVARIAN TUMORS Continued). 

Treatment. 

It is not necessary to interfere, in any manner, with some 3ases of 
ovarian dropsy. There are many instances which advance slowly : : 
remain stationary for a great many years, and prove but an incon- 
venience. We would not be justified in active interference in these : 
much less should we do anything directly for cases in which inder :.- 
dent complications of a fatal character exist, e. g.. phthisis or cancer, 
albuminuria, etc. When, however, the disease is making obvious 
progress, and particularly when the advance is sufficiently rapid to 
leave but little doubt of its proving fatal within the average time of 
their duration, we are bound to make every effort within our power to 
save or prolong, as much as possible, the life of our patient. 

The treatment of ovarian tumors may be divided into palliative and 
curative. The one intended to relieve, as far as possible, the suffer- 
ings of the patient under the disease, or to retard the rapidity of its 
progress ; the other to remove or destroy the tumor, and thus do away 
with the cause of the evil entirely. 

When doubt exists as to the propriety of instituting radical treat- 
ment, we should continue to pursue the palliative until that dout - is 
dispelled. There are three sorts of cases to which the palliative is 
indisputably adapted. They are, first, those in which, while there 
is a steady advance, in consequence of the absence and pro- 
remoteness of urgent symptoms, it is not desirable to use radical 
means. The second class of cases is that in which the symptoms are 
urgent, but in which it is not desirable to use radical means in con- 
sequence of the slight chances of success. The third are such as. in 
their nature and condition, would call for curative means, but the 
patient will not consent to their employment from fear of the danger 
or pain they inflict. The first set of cases is not very frequently met 
with compared to either of the others : yet we do occasionally meet 
with these slowly marching cases, in which we have an opportunity 
to try the effect of medicines ; and it is precisely in this kind of a - - 
that we appear to derive most benefit from medicines internally ad- 
ministered. We are apt to believe that the tardy development is 
dependent upon the virtue of some favorite remedy used, and de 
ourselves as to its efficiency, when really all depends on the natural 
slowness of the tumor. The alteratives, as mercury, iodine, sarsapa- 






TREATMENT. 731 

rilla, chlorine, etc., have all had their advocates. It was at one time, 
and even now is, the practice of some men of ability to give mercury 
to very slight ptyalism, with the hope of bringing about absorption. 
Iodine, administered frequently, so as to induce its specific influence 
upon the organism, has been, and is still, by some highly lauded as 
capable of curing ovarian dropsy. A chronic administration of either 
of these remedies is sure to affect unfavorably the general health ; 
and, as it is extremely doubtful whether there is any efficacy in them, 
we should not be too profuse in their use. Effusion into the perito- 
neal sac, or subacute inflammatory complications, are often very much 
benefited by a moderately protracted course of these remedies. For 
the same purpose, local depletion, counter-irritants, such as iodine 
ointment, strong enough to induce irritation of the skin, are often use- 
ful; so are diaphoretics, diuretics, and cathartics. In the second 
class of cases we need not feel so restricted in our efforts at palliation. 
It is best, however, to bear in mind that too great activity of medi- 
cation will often do more harm than good. Our object should be to 
promote such functions as are obstructed or restricted ; the kidneys, 
for instance, need especial attention, as also the intestinal canal. The 
acids have always seemed to me to be particularly applicable to these 
cases. The nitric, nitro-muriatic, sulphuric, phosphoric, acetic, are 
all useful, and may be alternated often with the hope of relieving 
the distressing indigestion attendant upon great distension and im- 
perfect performance of the renal functions. They also very much 
moderate the distressing exudations from the skin, which are often 
present. The chlorinated tincture of iron is also an excellent tonic. 
These remedies may very properly be administered in some of the 
bitter infusions, — quassia, chamomile, wild-cherry bark, etc. The 
best time to give them is immediately after eating. Stimulants ought 
not to be too freely used, as they encourage the establishment of com- 
plications. Brandy I think the best of the stimulants, and it should 
be given more for the purpose of inducing sleep than anything else ; 
and this it will often do when taken in a sufficient dose on an empty 
stomach at bedtime. When great restlessness and want of sleep are 
wearing out the patient, we must, as in all similar circumstances in 
other diseases, resort to the assortment of anodynes, beginning with 
the less disturbing, being sure to be under the necessity of ending 
with opium. Chloroform, internally administered, is, I am confident, 
not sufficiently relied upon. Teaspoonful doses, given in milk, will 
seldom fail to induce a fine anodyne effect. There is greater neces- 
sity, perhaps, for a gradual increase of the dose in using it than 
opium, or most other efficient anodynes. Hyoscyamus, belladonna, 
cicuta, should be all tried before opium. 

We must'be on the alert for complications, and ready for their 
appropriate treatment. The distressing constipation, which often 



732 OVARIAN TUMORS. 

annoys the patient and physician, will demand a great share of our 
attention. Injections of water and various substances will, of course, 
suggest themselves. It has occurred to me to be able to induce free 
movements of the bowels by having a pint of warm lard thrown high 
up in the bowels when they are very obstinate; the longer the lard 
is retained the better. This, administered once a day, will act excel- 
lently well sometimes. An ounce of fresh beef's gall, with three 
or four ounces of water, often does as well. But the time comes, 
sooner or later, with the steadily increasing pressure of the tumor, 
when to lessen its size is indispensable to the further extension of 
life. 

Tapping suggests itself as the only surgical palliative in this state 
of things. This operation is more beneficial in unilocular tumors 
than in any other sort, but is applicable as a palliative measure, in 
any tumor containing fluid, when demanded by the supervention of 
urgent symptoms indicating the necessity of immediate relief. Under 
the desperate circumstances mentioned, there can be no question about 
the propriety of tapping the patient; yet this apparently trifling 
operation is not devoid of inconveniences and dangers that should be 
weighed deliberately, and if they do not deter us from resorting to 
it, will at least make us particular not to use it as anything but an 
indispensable remedy. One serious inconvenience connected with 
tapping is the readiness with which the fluid accumulates in the sac. 

The dangers of tapping are both immediate and remote. The 
immediate are such as are connected with, and occur immediately 
upon, the performance of the operation. Dr. Simpson sums up five 
that are more frequent, and against which we should be upon our 
guard. First, the chance of wounding the urinary bladder. This 
may be avoided by evacuating the organ, unless it is tied to the ab- 
dominal wall by adhesions, which we can ascertain by introducing 
the sound. Second, the puncture of the uterus when it is drawn up 
with the tumor. By introducing the sound into its cavity we may 
learn its whereabouts, and thus be enabled to avoid it. Third, the 
front part of the tumor may be traversed by the Fallopian tube, and 
this last be wounded by the trocar. Fourth, the internal venous cir- 
culation, on account of the pressure, is obstructed sometimes, and the 
blood is directed to the veins in the walls of the abdomen or tissue, 
so that these veins may be wounded ; but generally they are large 
and may be seen, and thus avoided. Fifth, the epigastric artery is 
sometimes wounded. We should carefully feel for the pulsation of 
arteries in the thin walls before the trocar is plunged into the tumor. 
As may be seen, these dangers may, for the most part, be provided 
against; but the second class of dangers, namely, the remote, — those 
that follow some time after the operation, and are not dependent on 
the manner or place of the puncture, — are not so easily avoided. 



TREATMENT. 733 

The dangers and benefits of tapping cannot, and ought not, to be 
estimated by comparison with other operations. Each operation, of 
whatever kind, has its place, and is followed by its good or bad effects, 
for the reason, among others, that it is appropriate, or inappropriate. 
Generally, no two operations are applicable to any one condition of 
things ; and we should not allow the question of danger to decide be- 
tween them, unless in very rare and exceptional cases. The statistics, 
as far as 1 have been able to collect them, may be well summed up, as 
Dr. West has done, and I shall rely upon his figures: 

"The chief, indeed, almost the only numerical data of which we are possessed, bear- 
ing on this subject, are derived, from a table of 20 cases, compiled by Mr. Southam ; of 
45 cases collected by the late Mr. Lee; and of 64, the results of which are given by 
Professor Kiwisch. Of these 130 cases, 22 terminated fatally within a few hours or 
days after tapping, and 25 more in the following six months ; or, in other words, 34.7 
per cent, of the cases ended in the patient's death in the course of half a year after the 
performance of tapping. In 114 of the 130 death is stated to have taken place: 22 
within less than ten days, 25 within six months, 2"2 within one year, 21 within two 
years, 11 within three years, 13 after a period exceeding three, and in some amount- 
ing to several years. 

"In 109 of these cases, we are further informed how often the patients had been 
tapped. It appears that 46 died after the first tapping, 10 after the second, 25 after 
from three to six tappings, 15 after seven to twelve, 13 after more than twelve." 

It would appear that the first tapping is very much more dangerous 
than subsequent ones. Dr. West says further: 

"Unfavorable, however, as are the conclusions to which we are irresistibly led by 
such facts as those which have just been mentioned with reference to the ultimate 
issue of tapping, it is yet very questionable whether they represent the whole of the 
truth concerning this matter." 

Dr. Atlee, of Philadelphia, thinks tapping not a very dangerous 
operation. Mr. Brown thinks its dangers greatly overrated. 

There can be but little doubt that much of the mortality of tapping 
is due to the fact of the desperate character of the cases in which it is 
used ; and the reason why so many die in so short a time after the 
first operation is, that in many instances the patient is almost mori- 
bund before it is resorted to. When not attended with the imme- 
diate dangers above enumerated, tapping is either followed by great 
relief from suffering or by the remote or sequential dangers. They 
are, for the most part, prostration or inflammation. The prostration 
is sometimes so great that no management can prevent the patient 
from dying in a very short time. Such great prostration is, how- 
ever, exceedingly rare; it is more common to have it in a more mod- 
erate degree. The patient will feel faint for an hour or two, and 
then gradually rally, or she may continue to be pale and languid for 



734 OVARIAN TUMORS. 

several days. For such slight cases the horizontal position, rest, and 
good, digestible, somewhat stimulating food, is all that will be needed. 
When the prostration is great, and danger of fatal sinking present, 
the case must be treated energetically. The means calculated to 
bring about reaction must have reference to the causes of the pros- 
tration. The evacuation from the general vascular system is not a 
cause, because the fluid in the tumor is extravascular ; but it is a 
sudden change in the distribution of the blood. The evacuation of 
the abdominal cavity of so large a bulk of its contents, and the in- 
ability of the abdominal muscles to contract sufficiently to keep up 
the pressure to which the viscera have been habituated, are the 
causes of the irregular distribution of the blood. The want of pres- 
sure upon the abdominal viscera allows a large accumulation of 
blood in the veins, and it is there retained. In proportion to the 
amount thus collected in the abdomen, w T ill the blood be withdrawn 
from other parts and organs. The brain will partake of this tempo- 
rary anaemia, and consequently be incapable of discharging its func- 
tions with its wonted efficiency. This is the condition, — not a want, 
but an irregular distribution of blood. Our first object should be to, 
as nearly as possible, re-establish the previous condition of the abdo- 
men. This can be, to some extent, accomplished by pressure, with 
compresses and rollers. The compresses should be as large as the 
space covered by the muscles of the abdomen, and thick enough to 
fill up much above the level of the ribs and iliac bones on the side. 
The roller should be applied from the pubis to the ensiform cartilage, 
with as much power as the patient can bear without great discomfort. 
Then the head should be persistently kept below the level of the 
body. This simple treatment, instituted early, will do more than all 
other means without it. We can very properly, however, give stimu- 
lants, in addition, when necessary. When this danger is passed, 
inflammation of the sac or peritoneal cavity is next to be appre- 
hended. The sac undergoes every degree of inflammation, from the 
slow, subacute, unobserved degree, which vitiates the fluid effused 
into it, either by causing decomposition in it, or by the production of 
pus, or effusion of blood inside, or fibrin on the external surface — in 
this last case causing adhesion — or such degeneration of the walls of 
the sac as to cause an obliteration of the cavity, a cessation of its 
secreting powers, or a perforation, and consequent peritoneal commu- 
nication ; or. what is perhaps more common, an acute degree, an- 
nounced by severe pain, referred to the point most intensely affected, 
or to the whole abdominal region, thus showing the probable involve- 
ment of the peritoneum. Indeed, I think it very probable that the 
sharp pain ordinarily present in these cases, indicates peritoneal in- 
flammation, and that there is but little pain in the case of inflamma- 
tion of the fibrous and internal coats of the sac. Fever, of a some- 



TREATMENT. 735 

what high grade, is apt to attend upon the degree of inflammation last 
mentioned, accompanied by headache, weariness, aching in the back, 
limbs, etc. But in the inflammation of the inner coats, in which pus 
or fibrinous products are effused in the fluid of the tumor, there is 
generally but slight fever, perhaps none at first ; but the vital powers 
are more or less depressed, copious perspirations at night, possibly de- 
lirium, and in bad cases, all the symptoms of pyemia, hectic exhaus- 
tion and death. Now all morbid conditions resulting from tapping 
should be met promptly by the remedies appropriate to them when 
they occur under other circumstances, — antiphlogistic regimen, deple- 
tion, fomentations, cathartics, anodynes, alteratives, etc. In pyemia, 
tonics, stimulants, good diet, and time will be our resort. 

The operation of tapping is simple, and easily performed generally. 
To avoid the depression which follows the evacuation of so large a 
quantity of fluid as is contained in the abdomen sometimes, we should 
have our patient on the side, very near the edge of the bed, with her 
head and shoulders low. Two large and long hand-towels should be 
passed around her body, with the edges close together upon a level 
with the point where we wish to introduce the trocar, and these ends 
given to an assistant, who stands behind the patient. The assistant 
having in charge these hand-towels should be directed to draw upon 
them so as to keep up a state of tension as the fluid is being evacuated. 
To avoid the dangers enumerated as immediate, we should assure our- 
selves that the bladder is empty, and if we mistrust that it is not in 
its proper place, we should introduce a sound, so as to assure ourselves 
of the whereabouts of the fundus. If we have not already done so, 
we must sound the uterus, also, and thus be sure of its harmless 
position. After these precautions, the best rule, perhaps, is that given 
by the late Sir James Y. Simpson, and that is, to feel for the most 
fluctuating point, the place where the walls are thinnest, look for veins 
and feel for the pulsation of arteries. The thinnest part, where fluc- 
tuation is most evident, is usually the right place to make the punc- 
ture ; but there is not always any such point, there being but little 
difference in this respect over the whole of the front surface of the 
tumor. In such case we may be governed by the ordinary rules for 
the place for tapping. The linea alba, between the symphysis and 
umbilicus, is the most eligible in the greatest number of cases. If any 
objection to this arises, a point midway between the umbilicus and 
the anterior superior spine of the ilium is, as a general thing, safe 
and effectual as any. Some surgeons recommend other places as free 
from the objections that are sometimes urged against these points. 
They say that tapping through the vagina is quite safe from the 
immediate, and not so likely to be followed by some of the sequential 
disasters. The rectum is thought to be still better by some. The 
vagina is quite a commendable place, if we are careful to ascertain 



736 OVARIAN TUMORS. 

well the position of the bladder and uterus, and avoid thern. Our 
instrument (the trocar) should be large, four or five lines in diameter ; 
the point should be sharp, and a little longer than they are usually 
made. The canula if not large will not freely discharge the fibrinous 
concretions or thick treacle-like fluid, and if the point is not long and 
sharp, we inflict considerable unnecessary suffering in the introduction 
of the instrument. We may plunge the instrument in towards the 
central axis of the tumor, until sent home to the rim of the canula. 
If, however, our instrument is not pretty sharp, it will be very much 
better to make an opening through the integument with a very sharp, 
thin bistoury, which will cause less suffering, and answer every pur- 
pose as well. 

For the purpose of avoiding some of the dangers connected with 
tapping, Mr. Wells has invented a trocar that prevents the ingress 
of air, and attaches a rubber tube to the canula to carry the fluid 
clear of the patient and bed. 

I have never seen any serious effects follow tapping with these pre- 
cautions. Notwithstanding this favorable experience, I would advise 
every practicable precaution recommended by these eminent observers 
to avoid the disasters which have occasionally occurred. 

Since the general introduction of the aspirator many surgeons 
think it better practice to use that instrument in the evacuation of the 
tumor. It has been pretty well proven, however, by the late inves- 
tigation of Drs. Lusk and Proctor, that there is not so much differ- 
ence in dangers resulting from the use of the aspirator instead of the 
trocar, as was expected from the experience of Dieulafo} T and his fol- 
lowers. Several instances have been recorded in which death oc- 
curred from the use of the aspirator. 

The third sort of cases to which palliative treatment is applicable, 
those in which our patient will not submit to radical means, must be 
managed in almost every particular as I have described the treatment 
for the other two kinds. Remembering the rules and rationale, it will 
not be difficult to adapt our means to the end in view. 

Curative Treatment. 

The cure of ovarian tumors is believed by almost all authorities to 
be practicable only by surgical means. There are some very respect- 
able writers, however, who believe that there are cases in which we 
may hope for success from medicinal and mechanical treatment with- 
out the use of surgical instruments, and they think that there is enough 
virtue in such means to warrant a trial in yqyj man}' instances. 

Surgical Treatment 

The resolution and absorption of ovarian tumors is a very doubtful 
fact, however, and notwithstanding their unaccountable disappear- 



SURGICAL TREATMENT. 737 

ance, should not be counted prognostically. The second object in our 
treatment, that of obliterating the sac in situ, affords more reason for 
hope in properly selected cases. The means used consist of tapping, 
with pressure, with injections of stimulants to induce inflammation 
of the sac, and with injections and pressure combined ; or, what is 
sometimes successful, the establishment of a fistulous opening in the 
sac, that either communicates externally through the abdominal walls, 
through the vagina or rectum, or simply with the peritoneal cavity. 
The above-mentioned treatment is applicable, properly, to the uniloc- 
ular or single cyst cases only, as it is impracticable to tap, inject, or 
establish a fistula, when there are many sacs; and, what is still more 
discouraging in the multilocular variety, the sacs are not only filled 
again after tapping, as is generally the case with the monocyst, but 
there is a constant reproduction, or, perhaps, it would be more cor- 
rect to say that they are continuously developed from the ovisacs that 
are matured every month. Tapping, followed by pressure or injec- 
tion, is very apt to change the condition of the tumor in one respect, 
at least, and that is, to cause adhesions to the surrounding peritoneal 
surface. In one case of unilocular tumor, in which an external fistu- 
lous opening was made after the patient had been tapped six times, 
and had iodine injections three times, the sac, so far as we could de- 
termine, was universally adherent ; no portion of it could be brought 
out of the wound. 

Very fortunate instances sometimes occur in which the evacuation 
of the tumor by tapping is followed by a speedy and permanent 
obliteration of the sac. It is exceedingly doubtful, however, whether 
these were not cysts developed from the broad ligament, and not 
involving the ovarian tissues at all. Certainly they are exceptional, 
and cannot be expected in any given case, so that we ought never to 
be satisfied with tapping when our object is the obliteration of the 
cyst. 

Press are, in conjunction with tapping, is applicable, perhaps, to a 
larger number of cases than any of the modes of treatment yet men- 
tioned. It is very much more successful in cases of the monocystic 
than in any other variety. The application of pressure to a tapped 
sac has for its object a complete closure of the cavity of the cyst in 
such a manner as to bring its walls, as nearly as practicable, in con- 
tact throughout. This at once, if thoroughly effected, modifies the 
secerning capacity of its surface, and perhaps, from the time of its 
application, arrests more or less completely the effusion of the fluid. 
Now, if this cannot be done so as to operate upon all the surface of 
the walls, we can almost always bring some portion of the collapsed 
walls in contact. The continuous and prolonged contact of these sur- 
faces brings about a low, and in some cases a pretty high grade of 
inflammation, causing adhesion or a change in their structure, so that 

47 



73 S ovaeiax tumors. 

they are no longer of the same ovisac nature, and hence they do not 
effuse the thick albumen previously produced, and the tumor remains 
inactive or shrinks, and nearly or entirely disappears ; or suppurative 
inflammation may dissolve down and discharge the mass through 
some adventitious or natural outlet. 

The manner of applying the pressure is of the greatest importance. 
The apparatus should he permanent, and exert as much force as the 
patient can hear without too great pain, fever, derangement of the 
abdominal viscera, or other indications of too acute a degree of in- 
flammation in the cyst or damage to some organ. It should be ap- 
plied to the tumor as nearly as possible, and the forcible pressure 
should be exerted alone upon the collapsed mass, sc as to crowd it 
back against the sacrum, lumbar muscles, spine, and other hard parts 
of the posterior wall of the abdomen. In order to do this properly, 
after the fluid is evacuated as completely as possible, we should ex- 
amine the abdomen minutely, so as to ascertain as clearly as possible 
the position of the collapsed cyst. This will usually be a little more 
to one side than the other, and we may generally easily define its 
shape and get a good idea of its size. We should now construct a 
compact compress, corresponding in shape and size with the shape 
and size of the evacuated sac. The compress should be embraced by 
solid wood or tin outside. The compress can be made of hair, gum- 
elastic material, or napkins. If of the latter, they should be well 
stitched together, so that there can be no shirting in their position. 
After firmly attaching the soft portion of the compress to the hard, so 
that any pressure upon the latter may be exerted unvaryingly u] n 
the former, it may be placed immediately over the tapped tumor, and 

i — are applied from a direction to press it against the hardest v :. 
bearing on the posterior walls of the abdomen or pelvis. An a: en- 
tive examination of the tumor under the pressure of the instrument 
will inform us pretty accurately as to the efficiency, completer—-. 
and direction of the pressure of the compress. The compress : 
he managed better by a belt of soft but firm leather, to surround the 
body in such a place as to press over the centre of the com]: -- 
The power and direction of the pressure maybe regulated thoroughly 
and at will by subjecting it to a tourniquet screw pressure from the 
belt. Of course there must be thigh and shoulder-straps to the belt, 
in order 1 : from slipping up or down. When we have adapted 

these simple contrivances, we should turn the screw to such a degi 
as to press strongly as the patient can bear, and with it there 
regulate the pressure as we may judge best. Having thoroughly 
satisfied ourselves of the appropriate adaptation of the apparatus 

dd wrap the whole abdomen agreeably tight, from pub: al ste mum, 
with a flannel roller. We should every day remove the flannel roller, 
and examine the compress and belt to be sure that they are not dis- 



SURGICAL TREATMENT. 739 

arranged, and if in the least so, we should readapt them. We may 
tighten the screw or loosen it each time, or allow it to remain untouched, 
as the case may be. The greatest care should be taken not to produce 
too great pressure with this compress. It should be loosened when 
chilliness, febrile excitement, or other general signs of distress are 
added to local pain ; it may be tightened as soon as the symptoms 
decline. 

This mode of applying pressure, I think, is much more efficient and 
manageable than the plan recommended by the late Mr. I. B. Brown, 
of London, the accomplished surgeon of female diseases and injuries. 
His plan is to make a graduated compress of napkins so as to fit the 
top of the pelvis, and after applying it over the tumor, so as to press 
it down into the pelvic cavity and against its back part, place over 
the whole a broad bandage tightly fastened from pubes to sternum. 
This kind of compress cannot always be accurate in the extent, posi- 
tion, and rate of its pressure, and, consequently, much more skill 
and experience are necessary in its application. Its success, hence, 
was much more frequent in Mr. Brown's hands than it has been with 
the profession generally. I am not aware that Mr. Brown teaches 
the necessity of pressure to all the collapsed tumor, but understand 
him to make most of his pressure at the origin of the tumor, — the 
ovarian region. The tumor, when collapsed by tapping after great 
distension, seldom sinks anything more than partially into the pelvis ; 
the long-exercised traction upwards generally lifts the ovary of that 
side above the pelvis, and thus we may generally somewhat accurately 
fit our means to its slope and position. An objection, Mr. Brown 
thinks, sometimes applied to pressure, is the presence and great aggra- 
vation of prolapsus uteri. This objection, it will be apparent, is very 
much more applicable to his mode of causing it than the one I recom- 
mend. Multilocular tumors may be cured in this way perhaps more 
frequently than any other except extirpation, for the pressure may 
be made to bear upon and greatly influence the development of the 
small cysts that are not evacuated by pressure. I have more than 
once evacuated severaLsacs through one opening in the abdominal 
walls by partially withdrawing the trocar, and directing the point 
toward a full sac after the one first pierced had been evacuated. This 
should be attempted in a multilocular tumor before we use pressure, 
and it is allowable, I think, to introduce the trocar in several places 
where there are a number of cysts that cannot be reached by the in- 
strument from one point. I would not be understood as advising a 
reckless use of the trocar in these many-cysted ovarian tumors, but 
after we have decided from the circumstances of a careful examination 
of a given case that tapping and pressure is the treatment, we risk 
nothing, I think, in being thorough in our efforts to evacuate as nearly 
as possible all the sacs. The bad effects arising from tapping and 



740 OVARIAN TUMORS. 

pressure are inflammation and its consequences. When there are 
symptoms of severe acute inflammation, the pressure should be re- 
moved, and leeches, cathartics, etc., should be employed to moderate 
or remove it, If the inflammation is in the sac, we should wait until 
all the acute symptoms subside before the pad or compress is placed 
again. If, however, we can satisfy ourselves that the inflammation is 
in some other part distressed by the pressure, by varying the direction 
of the pressure, provided we can include the tumor under it, we need 
not wait until all the acute symptoms have vanished. I have a better 
opinion of this kind of treatment, when carefully managed and watched, 
than any other, except the complete extirpation of the ovary. 

Injection of the Sac. 

Another plan of obliterating the sac of ovarian tumors is to first 
evacuate, and then inject it with some substance calculated to induce 
inflammation in it, which, by its adhesive or destructive processes, 
may completely effect this object. A large number of cases are re- 
ported cured by this plan of treatment. For obvious reasons it is 
almost exclusive^ confined in its usefulness to the unilocular variety. 
Under certain circumstances only can we expect to reach more than 
one cyst at a time with the trocar and injections. When a cyst is 
simple, the patient in good health, and we succeed in properly man- 
aging the operation, there is not a great deal of danger, and we may 
reasonably hope for benefit from it. The most simple, and I think 
effective mode of operating, is to first draw off nearly all the fluid, 
except, say, one or two pounds, as well as we can judge of it, with 
a large trocar. After this is accomplished, we should pass an elastic 
catheter or other flexible tube through the canula of the trocar to 
the bottom of the cavity. With a hard rubber syringe we may in- 
ject the medicine, whatever that may be, through the catheter into 
the interior of the cyst. By using this elastic tube there is no danger 
of failing to carry the material to the part we desire to reach without 
its coming in contact with anything else, or being decomposed before 
it arrives at its destination. The formulae for this kind of injections 
are numerous, and several different substances used. Iodine seems 
now to be the substance generally employed. Dr. Simpson recom- 
mends several ounces of the tincture. Six ounces is probably enough 
to use at one time. I have used on several occasions six ounces of a 
mixture containing one scruple of iodine, two scruples of iod. potass, 
to the ounce of water. This is certainly iodine enough, if specific in 
its influence, to cure any tumor. My plan is to allow it to remain in 
the sac instead of removing any of it, 

Iodism is likely to occur to a slight extent, but is the source of 
no considerable inconvenience. If it should be thought best to re- 



INJECTION OF THE SAC. 741 

move a part, or the whole of the iodine, the better way to do it is to 
pump it out through the tube by which it was introduced, instead 
of squeezing it back through the canula of the trocar. This plan of 
extracting it, precludes the possibility of allowing any contact with 
the peritoneum; which in the event of disarrangement of the canula 
might otherwise take place. Although, ordinarily, no great amount 
of acute inflammation takes place as the effect of this injection, yet 
we should remember that it sometimes does proceed to a danger- 
ous extent, and be upon our guard with the means necessary to 
prevent a fatal degree. In fact, it would be negligence on our 
part not to watch with solicitude all the most trifling operations 
upon an ovarian cyst. It may be asked whether iodine is the best 
substance to use as an injection in such cases? Although I have to 
some extent fallen in with the fashion of using iodine, I cannot resist 
the conviction that there are substances that would do as well, against 
which some objections that apply to iodine could not be urged. 
Iodine operates promptly upon the organism when introduced in this 
way, by being absorbed and taken into the circulation ; yet, I think 
there can be but few who desire anything more than its local effect 
upon the inner surface of the sac. Alcohol, wine, brandy, in fact any 
local stimulant whose general effect after absorption is more transient, 
as well as less powerful, would perhaps answer just as well. It can- 
not be that the internal effects of iodine upon the kidneys and other 
organs of excretion can enter largely into its good effects, for if such 
were the case it would be better given by the stomach. Injection of 
iodine was regarded several years ago as the most eligible mode of 
treating this affection, because of its comparative safety and frequent 
success ; but there can be no doubt that it was overrated, and now 
the profession is less ready to trust it. I believe it to be both more 
dangerous and less efficient than pressure after tapping. This is not 
in accordance with the opinion of Dr. Simpson, I believe. I have 
lately known of a case in which death occurred after having been 
treated with iodine injections combined with pressure. I speak of 
this case to warn against a similar procedure, for it is plain, upon a 
little reflection, that if the pressure is properly applied, it will so lessen 
the cavity of the cyst as to endanger the effusion of the iodine, through 
the puncture in the sac, into the peritoneal cavity, and thus induce a 
fatal peritonitis. And if pressure is to be used, we should wait for 
two or three days after the injection. 

The last, and doubtless most effectual plan, for obliterating the 
sac, is the establishment of a fistulous opening, communicating with 
the peritoneal cavity, or the external surface, directly or indirectly, 
through the vagina or rectum. This is also the most dangerous plan, 
resulting fatally in a large number of cases. Quite a difference in the 
effects, both remedial and morbid, may be remarked in the different 



742 OVARIAN TUMORS. 

places for the fistulous opening. When properly and carefully man- 
aged, the opening in the peritoneal cavity is productive of least 
harm, and less likely to be followed by a cure. The opening in the 
vagina is more effective, and the direct opening through the abdomi- 
nal walls both more efficacious and more hazardous than any of the 
others. When a communication is perfected and perpetuated between 
the cavities of the tumor and the peritoneum, the surface of the latter 
being a better absorbing surface, the contents are absorbed, thrown 
into the circulation, and eliminated by excretion through the kidneys 
and alimentary canal. This process being carried on more rapidly 
than the secretion by the tumor, the latter is allowed to contract more 
and more, until its secreting surface is wholly lost, and indurated tis- 
sue is all that is left behind to mark its former existence. Some very 
important precautions are necessary for such happy results, as will 
appear by an attentive consideration of the subject. It is found, for 
instance, that sometimes the contents of the tumor are septic to the 
peritoneal lining of the abdomen, and may therefore cause fatal in- 
flammation upon its effusion into the cavity. We cannot say, without 
an inspection of the fluid, whether this is likely to occur upon per- 
formance of an operation or not, and I fear that we can by that means 
arrive at only a presumption upon the subject. In evacuating these 
growths for the first time we find, occasionally, clear, transparent, good, 
innocent-looking fluid begin to flow, when, as the flow continues, the 
latter part looks darker, grumous, and ill-conditioned. Xow, it is 
a question whether we might not be deceived upon inspection, and 
really furnish a virus to the surface of the peritoneum, instead of the 
bland albumen of the healthy ovarian tumors. However this may 
be, we do know, from cases placed on record by Dr. Simpson particu- 
larly, and observed not unfrequently, that these tumors do some- 
times burst into the abdominal cavity, and disappear, without any 
bad symptoms, so that we are justifiable in hoping the artificial open- 
ing may result well. Dr. Simpson recommends (and it is certainly 
the most sure way, although, as I have remarked, we must, under all 
circumstances, be in doubt), prior to opening communication with the 
peritoneal cavity, that we tap the tumor, and remove some of the fluid 
for examination, and if it is the ordinary bland, mucilaginous, trans- 
parent substance found generally after first tapping, he assures us we 
may proceed to the operation unhesitatingly ; or, rather, may keep 
the puncture in the sac open afterwards, instead of allowing it to close 
up, as it usually does. This is done by, in the first place, not re- 
moving nearly all the fluid from the sac by tapping, but allowing 
enough to remain to keep it partially distended ; and, in the second 
place, every twenty-four hours so to press upon the tumor as to well 
up the fluid through the opening in the sac, and thus break the slight 
adhesions which may have formed between the edges of the wound. 



INJECTION OF THE SAC. 743 

and allow it to escape into the peritoneum. Dr. Simpson thinks this 
is the safer way, so far as the danger from the operation is concerned, 
but, as will be seen, not so certain of accomplishing the object. He 
has cured cases in this way. The most effectual and the most danger- 
ous way is to cut down upon the tumor, and remove a piece from its 
wall large enough to insure patency, withdraw a part of the fluid, 
and then close the wound in the abdomen, and allow the rest of the 
fluid to flow into the peritoneal cavity thence to be absorbed. The 
immediate danger in this operation is that of dividing some of the 
bloodvessels which ramify through the walls of the tumor, and thus 
allow internal hemorrhage to take place. To avoid this it is recom- 
mended by Mr. Brown to draw out, examine, and divide only that 
portion which is clear of vascular ramifications. Others have recom- 
mended to tie any branch large enough to bleed. There is but little 
doubt that the precaution recommended by Mr. Brown would be suf- 
ficient to avoid that difficulty. The large wound through the peri- 
toneum makes the chance of inflammation in that membrane greater 
than the mere puncture of the trocar. Upon the whole, I think I 
should prefer Dr. Simpson's plan of keeping the opening made by the 
trocar in the tumor patent, by frequent well-directed manipulation. 
It ought to be practiced, I think, oftener than every twenty-four 
hours ; as often as every twelve, for the first two days. It will, prob- 
ably, be found, upon extensive trial, that it may not always be prac- 
ticable. Should there be adhesion at the point where the trocar 
passes, it would necessarily fail. 

The plan for making a fistulous opening externally is more prac- 
ticable, perhaps, than the one just detailed, from the consideration 
that it is more manageable. 

The operation is simple, and not attended with much immediate 
danger, the danger coming in the shape of acute inflammation soon 
after the operation, or exhausting suppurative inflammation and its 
attendants. Mr. Brown, who has given it a more extensive trial than 
anybody else, selects a point midway between the umbilicus and the 
anterior superior spines of the ilium of the side in which the tumor 
originated. His plan is to make an angular incision at this point 
down to the peritoneum, dissect up the angle from that membrane so 
as to completely expose it, evacuate the tumor through this exposed 
part with a trocar, stitch the sac to the sides of the opening, enlarge 
the puncture in the cyst, and keep it open by a pledget of lint or 
other substance, as he finds most convenient. Others cut down to the 
peritoneum, at a point midway between the umbilicus and symphysis 
pubis, stitch the sac to the sides of the wound, and keep open by lint 
or the stomach-tube. Care should be taken, especially if the contents 
of the sac should have a suspicious appearance, to prevent it escaping 
into the peritoneal cavity. Often there is adhesion at this part, when 



744 OVARIAN TUMOES. 

the stitches will not be necessary. This opening should be kept 
patent until the cavity of the cyst is lost by contraction, inflammatory 
adhesion, or granulation, or all these combined, which is probably 
the common mode of their disappearance. Some difficulty will be 
found in doing this, there is such a strong tendency in the wound to 
contract and heal up by granulation. If necessary, we may from 
time to time somewhat enlarge it with the knife, and we should not 
allow it to close until the discharge has entirely ceased. From what 
I can see of the dangers of this operation, they are very little, if any, 
less than those of ovariotomy, and I should not feel induced to resort 
to it unless it were in a simple cyst, where tapping, injection of iodine, 
or the use of pressure had entirely failed, or where, after exposing 
the cyst, ovariotomy was found impracticable from extensive adhe- 
sions. This I have done in one instance. The adhesions were so 
extensive that the cyst could not be removed ; in fact, they seemed to 
be about universal ; the incision was small, only admitting two fingers ; 
the sac had adhered at the point where the opening was made, so the 
incision was all that was necessary in the way of an operation. The 
patient died of acute peritoneal inflammation in three days afterwards. 
A post-mortem examination revealed extensive inflammation of the 
sac and peritoneum. 

Professors Kiwisch and Scanzoni, of Wurtzburg, were warm advo- 
cates of a fistulous opening through the vagina into the tumor, to be 
kept open until the same obliteration takes place that was spoken of 
as occurring in the case of opening through the front walls of the 
abdomen. Scanzoni operated on fourteen cases: eight resulted in a 
perfect cure: in two, the fluid collected again in a few weeks : one 
died of typhus fever two months after: and three were lost sight of. 
In none of the fourteen did death occur as a consequence of the pro- 
ceeding. He mentions one case only, in his whole experience, in 
which death occurred from peritonitis, and that was Professor Ki- 
wisch ? s case. Scanzoni admits its danger, but shows quite a favor- 
able opinion of it. Dr. West gives three cases of his own, two of 
which were cured, but had formidable inflammation ; the third died, 
not as an effect of the operation, but from something else, which he 
does not state. Scanzoni taps with a trocar through the vagina, and 
allows the canula to remain until the cure is effected.* This, of 
course, occupies a variable time. The tube is withdrawn by Scanzoni 
by the eight or tenth day in some cases. He says that some of his 
cases recovered without any sign of inflammation or other inconveni- 
ence. Dr. West operates by introducing the trocar and withdrawing 



* The only case I have operated on in this way died of pyemia from suppuration 
of the cvst. The canula remained for fifteen davs. 



ELECTROLYSIS. 745 

the fluid, passing a number twelve catheter through, and removing 
the canula over the catheter. The catheter is allowed to remain until 
the cure is complete. The cyst cannot always be reached from the 
vagina, and only in cases where it is crowded down into the pelvis, 
so as to give obvious fluctuation in that canal, should we think of this 
operation. 

When the cyst is discovered while yet small and occupying the 
posterior cul-de-sac, tapping and drainage will often result in a cure. 
I have once succeeded in obliterating a tumor as large as an orange 
by this method. Dr. Emil Noeggerath, of New York, thinks their 
growth may be arrested with much certainty by puncturing them 
with a very fine trocar or hypodermic syringe. He says he has 
treated about ten cases by this method, and is so well satisfied with 
the results as always to attempt the cure of small cysts in this way. 
He has also improved upon the operation of Kiwisch and Scanzoni 
by making a free incision into them through the vagina, and stitching 
the sac to the incision. He has thus succeeded in draining quite a 
number of large ovarian c} r sts. Another method of treating these 
small cysts, original with Dr. Noeggerath, consists in rupturing them 
by pressure between the fingers of one hand in the vagina and those 
of the other above the symphysis pubis * 

Electrolysis. 

Among the expedients for the treatment of ovarian tumors must be 
enumerated electrolysis, for although it has not been subjected to the 
test of experience, yet there have been a number of undoubted cases 
of cure by this process. 

Dr. Paul F. Munde, in an exhaustive paper, published in the second 
volume of American Gynecological Transactions, sums up the result of 
his research thus : " Out of fifty-one cases twenty-eight were either 
completely cured or permanently relieved. This makes about fifty- 
five per cent. Thirteen, or 25.4 per cent., were followed by dangerous 
and even fatal results, nine of which, or 17.6 per cent., proved fatal. 
Six cases were not affected by the treatment, and four were tempo- 
rarily improved. Thus in twenty-three cases, or 45 per cent., the 
objects of treatment were not attained." 

It is not fair, however, to compare the results of oophoro-electro- 
lysis with ovariotomy as practiced by expert ovariotomists, because 
electrolysis is in its infancy, while ovariotomy has undergone vast im- 
provements since it was first introduced. If we recall the time when 
ovariotomy was regarded as an unjustifiable operation on account of 
its want of success, and remember that the fatality of that operation 

* Second volume Transactions of the American Gynecological Society. 



746 OVA EI AX TUMORS. 

depended greatly upon the imperfection of its execution, and greater 
lack of skill in the after-treatment, we are warranted in indulging the 
hope that electrolysis may some day emerge from its present uncer- 
tainty and claim success to a degree sufficient to be applicable to cer- 
tain conditions of ovarian cases. 

There are two methods of applying electrolysis to ovarian tumors ; 
one is the external or percutaneous, in which the electrodes are ap- 
plied over the skin in such a manner as to allow the current to pass 
through the tumor. This method is less prompt and also less dan- 
gerous in its effects. 

Chiari reports a case in which there was great constitutional debility 
caused by some three hundred sittings. (Dr. Munde's paper.) 

The other plan of electrolyzing the tumor consists in inserting one 
or more needles into the tumor and connecting it or them with one 
electrode, while the other electrode is ap23iied over the surface of the 
tumor or in the vagina, or by applying both electrodes to needles in- 
troduced into different parts of the tumor. 

Experimenters in this practice are not sufficiently definite as to the 
kind of battery, the strength of current, the frequency or length of 
time of each sitting. These conditions, as well as the character of 
tumors likely to yield to the treatment, are points to be ascertained 
by further experiment. Neither is it yet determined whether the 
constant current or the induced is the better to use. 

Dr. Trommhold, of Buda Pesth, is reported by Semeleder to have 
cured an ovarian cyst by the external application of the Faradian 
current, 

For further information on this interesting subject, I would refer 
the reader to Dr. Munde's paper, and to one in the New York Medical 
Journal of June, 1876, by Dr. Frederic Semeleder. 

The third object in the treatment, partial or complete removal of 
the growth, remains to be considered. 

T 'agin a I Ovarioto m y. 

Several cases of vaginal ovariotomy are now on record, by Drs. 
Thomas, J. F. Gilmore, of Mobile, C. E. Wing, of Boston. W. Goodell, 
R. Davis, of Wilkesbarre, Pa., Robert Battey * Henry T. Byford, and 
W, L. Atlee, all of which were successful. 

The practice originated with Dr. Thomas. The operation consists 
in making a median line incision through the posterior wall of the 
vagina behind the cervix, puncturing the cyst, withdrawing it, and 
tying the pedicle. 

Dr. Thomas ligated and returned the pedicle, and closed up the 
wound. The most disagreeable circumstance following his operation 

* Emmet's Principles and Practice of Gynecology. 



VAGINAL OVARIOTOMY. 747 

was a smart attack of pelvic cellulitis. In Dr. Goodell's case the cyst 
was in a state of suppurative inflammation, and had contracted many- 
adhesions, which he overcame by introducing the fingers through the 
incision and traction with the vulsellum forceps. One of Henry T. 
Byford's cases was a small dermoid tumor firmly attached over the 
sacrouterine ligament, accompanied by an obliteration (or absence) 
of the vaginal portion of the sacro-uterine pouch. The difficulties, 
chiefly on account of the fact that the patient was a virgin, were great, 
but not insurmountable. His other case, a monocyst, was removed 
with great ease. Both recovered with scarcely any reaction. Dr. 
Atlee's case, the first on record (1857), consisted of a tumor dragged 
down between a prolapsed bladder and rectum, the ovarian origin of 
which had not, however, been previously discovered. 

The expediency of this operation is unquestionable where the diag- 
nosis is complete, because the favorable termination of the cases indi- 
cates a greater degree of safety than abdominal ovariotomy. 

I decidedly favor the idea of leaving a drainage tube in the vaginal 
incision for twenty-four or forty-eight hours, in conjunction with a 
tampon of loose iodoform gauze. The entire operation should be done 
in the dorsal position. 



CHAPTER XLIV. 

ABDOMINAL OVARIOTOMY. 

General Observations. 

During the time that surgeons were experimenting with different 
methods of performing ovariotomy, the incision was made in different 
localities, but now all operators make it in the linea alba, and between 
the umbilicus and the pubis. 

As to the length of the incision, the exigencies of the case must 
govern us. Three inches will often be sufficiently long to permit the 
removal of an oligocystic tumor with slight or no adhesions ; much more 
frequently, however, it will be necessary to make the incision five 
inches long ; very seldom will it be necessary to make it longer than 
this. 

Mr. "Wells thinks that incisions which do not extend above the um- 
bilicus are safer than those which do. Dr. Peaslee believes that the 
incision may be too short; less than three inches he thinks more 
dangerous than a greater length. The practical rule, according to 
Peaslee* (and I fully concur with it), is to make the opening into the 
peritoneal cavity for the removal of the tumor at least three inches 
long at first, then to prolong it if necessary, and only so far as is 
actually required. 

If the incision is to be carried above the umbilicus, it should be 
carried around to the left and then back to the linea alba. 

Treatment of the Pedicle. 

Mr. I. Baker Brown, according to Peaslee, first used the actual 
cautery to divide the pedicle. A clamp is first applied so as to secure 
and fix the pedicle, and then the cautery at a red heat is applied in 
such a manner as to cook the parts between the tumor and the clamp, 
and in the jaws of the clamp, and afterward to burn through the 
pedicle and thus separate it. 

If we have the iron at so low a temperature that we can make a 
prolonged contact and pass it over a larger space, the coagulation of 
the albumen in the tissue is so complete that there is no danger of 
hemorrhage. 

If, however, the cautery is very hot, it will sever the arteries with- 

* Ovarian Tumors, p. 417. 



THE LIGATURE. 749 

out consolidating the parts, and thus permit as free bleeding as if the 
division was made by the knife or scissors. 

The therm o-cautery of Paquelin, or the galvano-cautery, are the 
handiest instruments with which to cauterize the pedicle, but iron 
cauteries heated by properly constructed blowpipes, or a small porta- 
ble furnace, such as is used by tinners for soldering purposes, will 
answer better. 

Dr. G. H. B. McLeod, of Glasgow, first conceived and executed the 
idea of securing the vessels by torsion of the whole pedicle. He 
twisted it with two stout forceps. Torsion of the vessels separately 
has also been practiced successfully. 

The ecraseur has been used for dividing the pedicle. In my first 
case of ovariotomy I divided the pedicle with that instrument, and 
secured it in the wound with its edge upon a level with the skin by 
passing the pins through it with which I closed the wounds. 

Many other methods of securing the vessels in the pedicle have 
been devised, a thorough summary of which may be found in the 
admirable work of Dr. Peaslee, above mentioned, to which I would 
refer all who wish to study the subject in an extensive manner. 

The Ligature. 

The kind of material used for ligating the pedicle has engaged the 
attention of the profession for a long time. Silk, hemp, catgut, horse- 
hair, fibres from tendons of animals, — notably the deer, — metallic 
wire, etc., have all been used successfully, and most of them earnestly 
recommended by those who have tried them. 

Four qualities seem to be of material importance, if not essential to 
uniform success, viz. : 1st. Sufficient pliability to secure perfect adap- 
tation to the inequalities of the structure and density of the pedicle. 
2d. Strength to bear the force necessary to complete the constriction 
of the vessels. 3d. Solidity enough to resist the effects of moisture for 
a sufficient time. 4th. Absorbability. Of all the articles mentioned 
in the list I think silk is the only one that presents all these qualities 
to any desirable extent, and I think it is now generally regarded as 
the best material for ligation of the pedicle. 

The ligature should be long enough to enable the surgeon to manip- 
ulate it easily and handle it securely. If the pedicle is of sufficient 
length to permit of it, we should not apply it nearer than an inch to 
the tumor, and then separation should be made close to the tumor, 
thus giving almost an inch of tissue beyond the ligature. If the 
pedicle is too short for this we ought to cut into the tumor to lengthen 
out the substance beyond the ligature. This will do away with the 
danger of retraction and consequent loosening of the ligature. In a 
fleshy pedicle it is better also to ligate the arteries separately. I have 



750 ABDOMINAL OVARIOTOMY. 

known of one fatal case of hemorrhage resulting from retraction of 
the tissue of the pedicle through the ligature that I have no doubt 
might have terminated otherwise if these precautions had been 
observed. 

Should the ligature be cut short, or left out of the lower angle of 
the wound ? Dr. McDowell, in his first operation, tied the pedicle 
with a strong ligature, and left the end hanging out of the wound, 
and, before we learned how to use antiseptics, I have no .doubt that 
was the best way to use the ligature, as it kept the wound open and 
acted as a means of drainage. But such use of the ligature is incom- 
patible with antiseptic treatment, for the reason that it permits the 
ingress of septic particles. There can be no question that, as the 
operation is now done antiseptically, we ought always to cut the liga- 
ture short, return the pedicle carefully to its proper place, and close 
the wound as completely as possible. 

Drainage. 

Drainage is a question of much importance in ovariotomy, and in 
speaking of the subject it is well to consider it in two divisions, primary 
and secondary. 

By primary I mean its employment at the time of the operation, 
and, by secondary, the establishment of drainage any time during the 
after treatment. The two conditions for which I have employed 
primary drainage are, first, peritoneal drops} 7 , and, second, cases in 
w r hich we have been obliged to separate extensive and numerous 
adhesions. From these surfaces we are almost certain to have sero- 
sanguinous effusions, sometimes in considerable quantities. For the 
ascitic collection drainage is quite effectual. If the peritoneal mem- 
brane is not too much diseased We may expect that the cavity of the 
abdomen may be kept empty until a change in it causes a cessation 
of the effusion. When, as not infrequently is the case, there is an 
element of malignancy in the growth, the ascites will continue and 
add greatly to the exhausting influence of the disease. Of course the 
cases in which drainage is necessary are those of great accumulation, 
and not when the quantity is small. 

In the second class of cases drainage has a very restricted if not 
doubtful place. Experience must determine the question, in what 
cases is it useful. The tube does not permit the passage of blood to 
any extent, "When blood is extravasated in the abdominal cavity it 
coagulates and will not enter the tube, but remains, and I think often 
without doing harm. The serum set free by its separation from the 
coagulum if present in considerable quantities may for the first forty- 
eight hours find its way through the tube. Very soon, however, the 
fibrin in the serum coagulates about the tube forming an envelope 
that prevents the passage of anything. This is about what happens 



DRAINAGE. 751 

in drainage, and in most cases where it seems indicated is of doubtful 
utility. We may well ask whether closing the abdomen antiseptically 
when we expect some effusion is not better than to leave an opening 
with a tube in it that it is difficult if not impossible to keep free from 
sepsis. I think rubber makes the most reliable, manageable, and use- 
ful drainage tube. When prepared for use it is about three-eighths of 
an inch in diameter and four feet long, and the end to be inserted has 
a number of openings for about three inches. The perforated ex- 
tremity should be conducted by the fingers into the bottom of the 
retro-uterine pouch, and where the tube passes out of the wound it 
may be caught by the stitch in the lower angle of the wound to pre- 
vent it from slipping out. The free extremity of the tube is brought 
over the edge of the bed and placed in a jar full of a five per cent, 
solution of carbolic acid. By placing the dressing close around the 
tube we can pretty certainly exclude germs in that way, and they are 
prevented from entering the tube because it is submerged in the car- 
bolic water. A more commonly used drain is a straight or slightly 
curved glass tube with openings in the sides or end of it. It is about 
six inches long and has a lip to prevent its slipping into the abdominal 
cavity. The perforated portion is passed down behind the uterus and 
the other end extends through the wound. A sponge saturated with 
an antiseptic closely embraces the external end of the tube and the 
dressings are applied as usual. 

The object of secondary drainage is to evacuate fluids that are caus- 
ing septic symptoms. When the patient manifests decided symptoms 
of septicaemia there is a strong probability, indeed almost a certainty, 
that there is decomposing fluid in the peritoneal cavity, and that its 
evacuation will greatly improve the chances of recoveiy. The putrid 
material is generally in the cut de sac, and sometimes may be discovered 
by an examination through the vagina. We can frequently reach and 
remove this fluid by opening the posterior wall of the vagina and 
washing the pelvis out by simply throwing a stream of warm water 
that has been boiled to purify it, through the opening. The intention 
should be to wash out the pelvic cavity only. A drainage tube may 
be left in the opening for two or three days to facilitate the escape of 
such fluids as may not have been washed away. 

I am not prepared to advise the injection of mercurial or carbolic 
acid solutions into the peritoneal cavity, believing that if they are 
strong enough to be germicidal they are harmful ; and if not of that 
strength they are of little use. In desperate cases the life of patients 
have apparently been saved by reopening the incision and washing 
out the abdominal cavity with warm water and closing it up again. 
There is not much risk in doing this operation in the class of cases to 
which it is applicable, as their condition can scarcely be made worse 
by it. 



CHAPTEE XLV. 

ABDOMINAL OVAKIOTOMY {Continued). 

Before describing ovariotom}^ I propose considering some of the 
more important conditions presenting themselves to us, and which 
often embarrass the experienced operator. 

We should regard inflammation in the tumor, whether the tumor 
be large or small, with or without suppuration, as an indication for 
immediate operation, as the risks of the inflammation are very great, 
and are probably lessened by the removal of the tumor. This is 
especially the case if the inflammation is attended with hectic sjmip- 
toms. 

Although rupture of the cyst and effusion into the peritoneal cavity 
is not always attended with grave symptoms, yet the supervention of 
peritonitis to a serious degree, or septicaemia which threatens life or 
the general welfare of the patient, demands the operation for the 
removal of the tumor, large or small, and drainage of the peritoneal 
cavity. 

Pregnancy neither absolutely contraindicates nor demands ovari- 
otomy. Unless there is very injurious pressure from distension, the 
operation is not demanded, and we should wait for that condition 
before we determine to interfere in any way. When dangerous pres- 
sure does occur, if the tumor is multilocular to such a degree as to 
make it impossible to remove any considerable quantity of the fluid 
by tapping, the choice lies between evacuating the uterus and remov- 
ing the tumor. Dr. Barnes is in favor of inducing abortion first, 
and removing the tumor after the patient recovers from this operation, 
and the symptoms require it ; while Mr. Wells advocates and prac- 
tices the removal of the tumor, and a nunber of successful cases attest 
the soundness of his judgment. If, however, the tumor is oligocystic, 
or presents a large sac from which a great quantity of fluid may be 
removed, and much room thus gained, the tumor may be tapped once 
or several times until gestation is completed. I have in this way 
treated two cases, in which gestation went on to term, and the patients 
gave birth to living, healthy children. From one of these I removed 
the tumor six months after the child was born j the other, although 
the child is nearly a year old, is still carrying her tumor with compara- 
tive comfort. 

Sometimes errors or carelessness in diagnosis lead us into mistakes 
of so grave a character as to call for unexpected resources. One of 
them is the unsuspected coexistence of pregnancy and ovarian tumor, 



PEEGNANCY WITH THE TUMOE. 753 

and the wounding of the gravid uterus during the operation. I have 
collected the following cases as illustrative of the proper method of 
managing them. 

The rarity of this class of cases, and the interest attached to them 
in a diagnostic and therapeutic sense, leads me to report the following 
case of my own, and to present all I can find of a similar character :* 

A physician from a neighboring city visited Chicago, accompanied 
by a patient, to consult me about an ovarian tumor. The physician is 
a man of the highest standing in the profession, and of unquestionable 
integrity and honor. 

The tumor had been first noticed about one year previous to my 
seeing the patient, and had grown more rapidly in the last six months. 
The diagnosis given by the doctor was easily verified, viz., an ovarian 
tumor, most likely originating in the left ovary, and probably mono- 
cystic in character. The patient was an unmarried lady, twenty-three 
years of age, very modest in her demeanor, and, as I was assured by 
friends, of unblemished reputation. The cessation of the menses had 
occured at an uncertain period, expressed by the term "several months 
since." Before visiting the city, her physician had proposed a vaginal 
examination, as one of the means of adding certainty to the diagnosis; 
but the patient begged so hard to be spared from what she regarded 
as a humiliation, that he was induced to yield to her wish. When I 
investigated the case, she shrank from it with much earnestness, and 
very plausibly contended that it could not be necessary, as neither of 
us seemed to have any doubt as to the presence and nature of the tu- 
mor ; consequently I, too, omitted this important means of diagnosis. 
At this interview it was determined that an operation could not be long 
postponed, and that, as soon as arrangements could be made, I should 
remove it at her own home. 

Accordingly, in about two weeks, I was informed that everything 
was in readiness, and the patient desired to be relieved at once. Upon 
my arrival, I met four physicians, besides the attendant, and in their 
presence another careful examination was made, and as before, and for 
the same reasons, vaginal exploration was dispensed with. All, how- 
ever, seemed perfectly satisfied with the correctness of the diagnosis, 
and the necessity of an operation for the removal of the tumor. 

Preparations were at once perfected, the patient etherized, placed 
upon the table, and an incision about three inches long in the linea 
alba exposed the sac. After assuring myself that there were no ad- 
hesions on the anterior surface, I introduced Spencer Wells's trocar, 
and drew off about twelve quarts of an amber-colored fluid. The 
fluid was thin, but somewhat viscid, presenting the appearance I "had 
often witnessed in ovarian tumors. When the sac was nearly emptied 

* From American Obstetrical Journal. 
48 



754 ABDOMINAL OVARIOTOMY. 

I noticed a tumor behind it. adhering to the sac and preventing it 
from passing out through the incision. The second tumor was elastic. 
and so perfectly resembled a secondary cyst that I had no hesitation in 
plunging the trocar through its walls, with a view still further to 
Lessen the hulk of the entire mass by evacuating its contents. As 
the trocar met with unusual resistance, and nothing but blood passed 
through it. I became convinced that there was something unusual 
about it. The incision was somewhat enlarged, and as much of the 
emptied sac drawn out as would pass, when it was discovered that 
slight adhesions, and not continuity of tissue, connected the two. 
After the cyst was entirely withdrawn. I was astonished to find that 
the second tumor was the impregnated uterus, and. still worse, that 
it was wounded and bleeding. This revelation was accepted with 
many doubts by the physicians present, who were the Mends and 
neighbors of the patient, and believed it impossible that she should 
be pregnant. The facts were bo patent, however, as soon to overcome 
their incredulity. 

At that moment I did not call to mind an almost precisely similar 
instance that had occurred to Mr. Weils, and could not recall a prece- 
dent for my guidance. The wound in the uterus had been very much 
enlarged by the contraction of the transverse, oblique, and longitudi- 
nal fibres of that organ, until, in the few moments that had elapsed 
since the puncture, it had become as large as a silver dollar. It 
seemed to me. in the short time I had for reflection, that the only 
way out of the difficulty was to evacuate the uterus. This was done 
by making an incision about four inches long from near the fundus 
downwards, so as to include the accidental aperture. The incision 
exposed the placenta at about the middle of its attachment. This 
organ was easily and rapidly separated by passing the index finger 
between it and the uterine walls, and completely removed. After 
this was done, the right side of the foetus, the arm, hip, and feet were 
perfectly exposed. The breech was seized and drawn towards the 
opening, when the foetus was expelled by uterine contraction. The 
membranes and liquor amnii were next removed, when the uterus 
was perfectly devoid of all its former contents. 

Gestation had advanced to about the middle of the seventh month. 
The foetus evinced no signs of life after its removal, and had doubt- 
less died from the effect of hemorrhage from the wounded placenta. 

The incision in the uterus was closed by interrupted sutures of fine 
silk, including the visceral peritoneum, the whole of the muscular 
wall, and the mucous membrane. The sutures were cut short, and 
no provision made for their removal. By the time the sutures were 
all inserted and tied, the uterus had contracted very firmly. 

Thanks to the valuable aid afforded me by the gentlemen present 
(whose names for obvious reasons I dare not mention] neither blood, 



PREGNANCY WITH THE TUMOR. 755 

nor amniotic nor ovarian fluids had found their way into the peri- 
toneal cavity. 

In order to secure a free exit of the lochia from the cavity of the 
uterus, and thus prevent the danger of its passing through the wound, 
the os uteri was freely dilated with the finger, and a long flexible 
catheter left in it some hours. The pedicle of the ovarian cyst was 
tied with a double ligature of plaited silk, and returned into the ab- 
dominal cavity. The ligatures were brought out at the lower angle 
of the wound, and left long enough to hang down between the 
thighs. The wound in the abdomen was closed by interrupted 
sutures, and dressed with a thick layer of carbolized cotton batting. 
The only interest connected with the future progress of the case is, 
that there was not a disagreeable symptom, except a few trivial after- 
pains. 

After the operation was concluded, I was consoled for my error in 
not making a vaginal examination, and consequent ignorance of the 
complicating pregnancy, by the assurance of all the gentlemen who 
assisted me, that their confidence in the chastity of the patient was 
equal to their reliance upon the faithfulness of their own wives, and 
that a suspicion of her purity would not be entertained by any one 
who was acquainted w r ith her. Her complete recovery, however, 
and up to the present time her own entire ignorance that a foetus had 
been removed with the tumor, together with the preservation of her 
reputation, which could not have been done by any other course, 
fully compensates me for the chagrin I felt for all my shortcomings 
in the case. 

I have purposely omitted names, dates, and places, to avoid the 
possibility of identification of the patient ; I am persuaded, however, 
that this will not detract from the interest of the case. 

As the subject and manner of closing the wound in the operations 
for gastro-hysterotomy is now under discussion, I would call atten- 
tion to this part of the procedure. The entire absence of septic or 
inflammatory symptoms, I think, gives evidence that there was no 
escape of blood from the edges of the wound, or from the uterine 
cavity into the peritoneal sac, and warrants us in assuming that the 
closure by sutures was judicious, if not the all-important condition of 
success. After the operation, it was quite apparent that a great 
change must take place in the relation of the edges of the incision in 
the uterus, to allow the least drainage into the peritoneal cavity. 

The frequent occurrence of pregnancy during the growth of ovarian 
tumors is recognized by all experienced ovariotomists, and is a subject 
for consideration in all instances where a diagnosis is to be made 
preparatory to the removal of the tumor. Under ordinary circum- 
stances, the diagnosis of this complication is not very difficult, as the 
uterus lies anterior to or on one side of the tumor, so that its presence 



756 ABDOMINAL OVARIOTOMY. 

and contents are easily ascertained, but exceptional cases are some- 
times found when the difficulties are sufficient to mislead an ex- 
perienced and accomplished observer. Mr. Wells acknowledges mis- 
takes in his own practice, and mentions the fact that Dr. J. Marion 
Sims fell into an error of diagnosis and did not discover the compli- 
cation until the gravid uterus was exposed during the operation for 
the extirpation of the ovarian tumor. A considerable number of 
other cases might be cited in which mistakes of this kind have 
occurred. The probabilities are that more of these errors arise from 
insufficient scrutiny in cases where the diagnosis might be made, than 
from an entire impossibility to ascertain the true state of things. 
Our improved methods of examination, and more perfect knowledge 
in interpreting the phenomena of pregnancy, ought to secure us 
against errors of this kind in all but the very rarest combination of 
circumstances. 

As the known cases in which the double operation of ovariotomy 
and hysterotomy has been performed are very few, I have collected 
all I could find with my limited means of research, and will not 
apologize for reproducing them in a condensed form in this connec- 
tion. 

Mr. Wells publishes a case, alluded to above, in his well-known 
work on Diseases of the Ovaries, almost exactly like the one I have 
recorded. It was first reported in the Medical Times and Geizette of 
September 30th, 1865. 

He had entirely overlooked the existence of pregnancy with ova- 
rian disease, and after removing an adherent multilocular cyst of 
the left ovary, he felt what he thought was a cyst of the right ovary, 
— tapped it. and then found it was the gravid uterus. From this 
puncture two or three pints of bloody fluid escaped through the 
canula, when the tumor became much less tense ; and he says on 
raising the tumor up. he saw the Fallopian tube passing from its 
upper part, and thus he knew at once he had punctured the uterus. 
He says : 

" On withdrawing the canula, a soft, spongy, bleeding mass protruded, and on putting 
in my finger to push this back and examine the uterine cavity, the anterior wall of the 
uterus, which was very soft and friable, as it had undergone fatty degeneration, gave 
way along the middle line from the puncture (which was near the fundus) for an ex- 
tent of from three to four inches down the body toward the neck. With very slight 
presstire a quantity of liquor amnii and a foetus of about five months escaped. I then 
easily peeled off the placenta from the inner surface of the uterus ; the organ did not 
contract, and there was free bleeding from three vessels close beneath the peritoneum 
at the lower angle of the rupture in the uterus. These vessels were secured by three 
silk ligntures. Oozing still going on from the surface where the placenta was attached, 
I made a free opening into the vagina by passing my finger from above through the 
cervix and os, and then put a piece of ice into the uterus and held it within by firmly 
rasping the organ, which then contracted. I then brought the peritoneal edges of 



PREGNANCY WITH THE TUMOR. 757 

the tear in the uterus together by an uninterrupted suture of fine silk, one long end of 
which I had previously passed into the uterine cavity and out through the os into the 
vagina. By seven or eight points the edges were brought accurately together, and 
the other end of the silk was brought through the opening in the abdominal wall, with 
the ends of the three ligatures on the vessels in the uterine wall close to the pedicle, 
and were tied to the clamp." 

The patient completely recovered. 

I am indebted to Dr. Munde for the following very interesting 
case, published in the Australian Medical Journal, of February, 1875, 
by Thomas Hillas, M.R.C.S., Eng., of Victoria, Australia : 

"Mary McC, aged twenty-four years, single, was admitted to the Ballarat District 
Hospital, June 4th, 1872. The history of her case was peculiar. She believed that 
she became pregnant in March, 1871, and, not wishing to be confined in the district in 
which she lived, she sought admission to the lying-in ward of the Ballarat Benevolent 
Asylum. She was admitted there in November, 1871, and after staying there until 
the following June, a consultation of the honorary staff was called, and she was dis- 
charged, her case being deemed ovarian dropsy, and not pregnancy. On her admis- 
sion to the hospital she was examined by the resident surgeon, and subsequently by 
the honorary surgical and medical staff, all agreeing that she was suffering from ova- 
rian dropsy, and that it was a suitable case for operation. On Jnne 13th, assisted by 
the honorary surgeons, Messrs. Nicholson and Whitcomb, and the resident surgeon, 
Mr. Owen, and the honorary medical staff, the patient being under chloroform, I com- 
menced the operation, by an incision midway between the umbilicus and pubes. On 
arriving at the peritoneum, I made a small opening into it, when out spurted a large 
jet of venous blood, which the pressure of the finger controlled. I came to the con- 
clusion that I had wounded, unwittingly, a gravid uterus, and, feeling sure of this, 1 
extended the first incision upward to the umbilicus, when a large uterus rolled out on 
to the thighs, and the ovarian sac protruded. This was tapped, and about eleven 
quarts of fluid were drawn off; there were but few adhesions, which were easily broken 
down, and there was no hemorrhage. The sac contained about a dozen small cysts, 
but, the external wound being large, there was no occasion to tap them. The pedicle 
was short and thick, and, after being tied firmly with a double whipcord ligature, the 
clamp was securely applied, and the pedicle divided, the ends of the double ligature 
being tied over the ends of the clamp. Now came the difficulty. The uterus was all 
this time lying on the thighs, with the foetus in it, and a wound through its muscles, 
probably into the placenta. Some of the bystanders advised that the wound in the 
uterus should be sewn up, and that organ replaced in the abdomen ; but seeing that 
labor must come on soon, and that the rupture of the uterus would most likely occur 
at the seat of injury, I personally decided to perform the Csesarean operation as being 
the most likely means of giving the patient a chance to recover. The uterus was in- 
cised to about five inches, and the placenta and a foetus, alive and well developed, at 
about the eight month of gestation, extracted. I then stitched up the wound in the 
uterus with about nine or ten silver-wire sutures, carefully tucking the cut ends down 
into the incision. Immediately on completing this the uterus contracted firmly. I 
then sewed up the wound in the abdomen with deep and superficial stitches, the deep 
stitches including the peritoneum, leaving the clamp at the lower margin of the wound, 
and a good deal dragged upon. The right ovary was the one affected, and the patient 
measured sixty inches around the abdomen before the operation. The sac and its con- 
tents, after removal, weighed thirteen pounds, and are preserved in the hospital dis- 



758 ABDOMINAL OVARIOTOMY. 

pensary. The patient vomited for about forty- eight hours after the operation, having 
been an hour under chloroform. This was relieved by morphia and ice, and on the 
fourth day all unfavorable symptoms abated. There was a discharge of pus from the 
lower portion of the wound, which ceased in about a fortnight, and then completely 
healed. She was discharged, cured, at the end of six weeks. On July 3d, a month 
after the operation, she menstruated moderately for four days, and again on the 28th 
of August. I have seen her several times since, and she is in perfect health." 

Dr. Munde also kindly sent me the following three cases which, 
although not exactly corresponding to the cases already reported, 
will doubtless be of interest in this connection. The chances of 
saving the lives of the patients would undoubtedly have been in- 
creased if the operator had, in the first case, removed foetus and 
tumor, instead of leaving both untouched; and in the second, the 
tumor as well as the child. They will serve as a warning to others 
not to commit the same error : 

" Dr. Erskine Mason reported to the New York Pathological Society in 1877 the 
ease of a patient, thirty years of age, single, who entered Roosevelt Hospital, July 
30th, 1877. Since eighteen months increase of abdomen, the circumference of which 
at umbilicus measured thirty-nine inches. A vaginal examination showed the uterus 
high in the pelvis and movable. Distinct fluctuation in abdomen ; area of flatness not 
changed by position of patient. Diagnosis of ovarian cyst confirmed by one of the 
most expert ovariotomists of New York city. Ovariotomy was considered indicated. 
On opening the abdomen a cyst appeared, which was opened by the trocar, and eight 
ounces of fluid evacuated, when this cyst was found to be the pregnant uterus. The 
trocar wound was closed by sutures, and the abdominal wound also united. Patient 
gave birth the next day to a six months' foetus. Death of collapse eighteen and a 
half hours after operation. Autopsy showed large multilocular cyst of left ovary. 
Uterus well contracted ; no peritonitis." 

Of the second .ease, Dr. Munde says : 

" I have looked over Olshausen's recent work on Diseases of the Ovaries, and found 
mention of only one case of Csesarean section complicated with the presence of an 
ovarian tumor. The operator was Kob, of Stolp, in North Germany ; the original 
article appeared in the Transactions of the Berlin Obstetrical Society for 1873 ; Beitrdge 
zur Geburtshulfe und Gyndk&logie, vol. ii., p. 99. I have this work, and abstract the 
case briefly, as follows : 

"Patient forty years ; had four children ; pregnant near term with fifth. Found 
pelvis occupied by a dense, fluctuating tumor, preventing entrance of the head. The 
patient was much debilitated by this presumably ovarian growth. Finding the passage 
of the child impossible through the normal pelvis, the tumor was punctured per 
vaginam, but. only thick colloid imucus flowed out in small quantities, even after enlarge- 
ment of the puncture with the bistoury. Finally the Csesarean section was performed, 
ihe child extracted alive and continued to live. The wound was closed by thread 
sutures, and death followed on th« third day, probably from septic peritonitis. The 
.cyst was not removed, although special mention is not made of the necessity (the author 
probably looked upon it as malignant, as colloid tumors were formerly so regarded, 
; and, therefore, thought its removal superfluous) ; but he states that, after the operation, 
colloid matter still escaped from the vaginal puncture. The operation was performed 
January 17th, 1873." 



PREGNANCY WITH THE TUMOR. 759 

The third case was reported by Professor Lahs, of Marburg, in 
the Deutsche Med. Wochenschrift, February 2d, 1878 : 

" L. was called to a pluripara in labor presumably eight days ; found abdomen much 
enlarged, fluctuation all over; firmly adherent cyst of left ovary filling pelvic cavity 
and obstructing delivery. Csesarean section; three silk sutures in uterus; cyst too 
firmly adherent to be removable. Death from collapse in twenty-four hours." 

In this case no blame can be attached to the operator for not re- 
moving the tumor, the firm adherence of which to the pelvic cavity, 
and the prostration of the patient from her long labor, rendering so 
severe an undertaking unjustifiable. 

Mr. Wells says, with reference to the question : 

" What should be done when a pregnant uterus is discovered during some stage of 

ovariotomy? Let it alone But supposing the operator has penetrated the 

uterus or wounded it? If any conclusion can be drawn from the case in which I made 
this mistake, and emptied the uterus, and two other cases, in which the same mistake 
was made by other surgeons who did not empty the uterus, but closed the puncture in 
its walls by wire sutures, and both patients died after aborting, while mine recovered, 
it would seem to be the safer practice to empty the uterus." 

The soundness of this teaching must receive the sanction of com- 
mon-sense, and is happily confirmed by the result of the two addi- 
tional cases, one published by Mr. Thomas Hillas, of Victoria, and 
the present one by himself. It will also be noticed that the treatment 
of the wound in the uterus, and the manner of closing the incision in 
that organ, had an important bearing on the subject in all three of 
these successful cases. Mr, Hillas closed the wound with interrupted 
silver sutures, Mr. Wells with an uninterrupted silk suture, while mine 
was closed with interrupted silk sutures. From what I could see of 
the more immediate effect, as well as from the final result, I cannot 
doubt that this procedure had much to do with the recovery of my 
case. Although Mr. Hillas makes no mention of his having secured 
a free exit for the discharge from the uterus by dilating the cervix, it 
is to be presumed that he did not neglect this precaution. Mr. Wells 
passed his finger down from the cavity through the cervix and os, 
while in my case I opened the cervical cavity with a large catheter. 
I think it is but fair to state that while these three cases were treated 
so essentially alike by all of the operators, neither of them was aware 
that there was any precedent for it. I certainly did not remember 
Mr. Wells's case at the time I operated, and I believe Mr. Hillas, like 
myself, had overlooked it. 

Other considerations hearing upon the question of ovariotomy, as 
advanced phthisis, serious organic disease of the heart or kidneys, or 
malignancy of the tumor, in all, or any of these conditions, I would 
refuse to perform ovariotomy and resort only to palliative measures. 



760 ABDOMINAL OVARIOTOMY. 

We will often meet with cases that have been neglected until pres- 
sure has impaired the nutritive functions to such an extent that the 
recuperative powers of the patient have been greatly reduced. In 
some of these cases we may improve the general condition of the pa- 
tient by tapping the tumor and restoring nutrition by proper meas- 
ures. This should be attempted when there is a cyst from which 
we can reasonably expect to draw off a large quantity of fluid. If, 
however, the distension is caused by the growth of a multilocular 
tumor, with only small or moderately sized cysts, we should risk the 
operation without loss of time or addition of the risk of a fruitless 
tapping. 

When the tumor is not large, or has been reduced by tapping, we 
should resort to tonics, abundant and nutritious diet, and surround 
the patient with the best hygienic conditions possible until her health 
is sufficiently restored to enable her to sustain the effects of the opera- 
tion. 

There are mental conditions which increase the hazard of an opera- 
tion. 

When a patient is very greatly depressed on account of bereave- 
ment, or other causes of intense grief, the indications should be very 
urgent to justify the immediate removal of the tumor; indeed, if it is 
possible, we should allow sufficient time for reaction from such a state 
of depression. I feel sure that I lost one patient because I could not 
pay sufficient attention to this condition. 

Courage on the part of the patient is an important item in assuring 
success in ovariotomy, and we should inspire the patient with hope 
by every possible means. The most favorable view of her case should 
be presented to her, and every means taken to help her to expect 
recovery, instead of leaving doubt in her mind. 

The menstrual cycle affords a time when the operation is more 
promising, and I think there is no doubt that we should operate as 
soon as the menstrual flow has subsided, if possible. 

The time of year in this climate is not a matter of so much import- 
ance as in warmer latitudes. 

I would rather operate in the warm than in the cold season, as ven- 
tilation can be secured much more easily at such times than during 
the inclemency of the winter season. 

If we can command the time, without serious inconvenience to the 
patient in reference to the size of the tumor, it would be better to select 
a period between the two extremes of temperature. 

The best place for the operation, if the patient has a comfortable 
home, is at her private residence instead of a hospital, unless it is one 
in which isolation and good ventilation can both be commanded. 

A well-organized special hospital, in consequence of the good atten- 
tion always at hand, is probably the next best place. When the patient 



PREPARATION. 761 

comes to the city in a good condition for ovariotomy the operation 
should not be delayed lest the health of the patient be deteriorated by 
the urban or hospital atmosphere. If the operation is to be performed 
in a private house, the room should be selected with a view to good 
ventilation, quietude, and cleanliness. Mere convenience is not a 
sufficient reason for the choice of rooms, as no sacrifice is too great if 
it will insure success. 

Preparation of the Room. 

The room should be stripped of all furniture and hangings, the car- 
pets and wall-paper be removed, closets communicating with it be 
emptied, and the room and closets thoroughly cleansed and white- 
washed. After a complete scrubbing and washing, the woodwork, 
including the floors, ought to be rubbed with a solution of the bichlo- 
ride of mercury 1 to 1000 or a 5 per cent, solution of carbolic acid. 
The outside windows and doors should remain open until the room 
is dry, then all closed and an iron pot holding several pounds of sul- 
phur placed in the room and the sulphur ignited. While the sulphur 
is burning, and for several hours after, the room is kept closed. It is 
believed that this process will disinfect a room that has not been more 
than ordinarily exposed. A single iron bedstead, mattress, bedding 
two chairs, and a table, all new, is sufficient furniture. In cold wea- 
ther the warmth of the room should be preserved by an open fire- 
place, and not by stove or furnace. If the room is not used immedi- 
ately after the preparation, it should be kept full of carbolized spray 
from a 5 per cent, solution until ready to begin the operation. 

It is hardly necessary to state that a good, faithful, and intelligent 
nurse is indispensable. The care of the patient should not be com- 
mitted to interested relatives unless they possess the information 
requisite for correct treatment. 

Preparation. 

The personal supervision of the patient is a matter of the first im- 
portance. All of her functions, especially those of the skin, kid- 
neys, and alimentary canal, should be regulated, if they need regula- 
tion, before placing her upon the table. The first by means of a warm 
bath, the second by the administration of some preparation of lithium 
or the acetate of potassium, and the third by the administration of a 
gentle but thorough cathartic ; castor oil is ordinarily the best. Meas- 
ures should be taken to keep up the action of the skin and kidneys. 
The under-garments should be woollen, and cover the patient from 
the throat to the feet, and enough changes secured to keep them clean 
and fresh, and the secretions encouraged by the administration of 



762 ABDOMINAL OVARIOTOMY. 

plenty of fluids, of which cold water is the best. The urine must be 
watched and its quantity and character regulated. 

During the operation the patient should be, as near as practicable, 
covered, her extremities especially, with her woollen garments.- 

The personal preparation of the surgeon, assistants, and attendants 
should be equally careful. Perfect cleanliness in them is a matter of 
paramount importance ; to this end, ablution of the hands and cleans- 
ing the nails must be thorough immediately preceding the operation. 
All of the articles used in the operation should also be as clean as 
possible. Every preparation should be made that will conduce to the 
convenience and easy access to every part of the patient by the sur- 
geon and the assistants. A table of convenient size, say five feet long 
and twenty inches wide, and high enough to enable the surgeon to 
stand erect, should be placed near an abundant source of good light, 
and yet so that all may pass around it with ease. The table should 
be prepared by covering it with a comforter or blanket, and a pillow 
placed on the end most remote from the light. 

When ready, the patient should be thoroughly etherized, preferably 
in bed, and placed upon the table, her wrapper drawn up close undei 
her arms to prevent it from becoming soiled, and the abdomen covered 
with a rubber blanket, with an opening eight or ten inches long, and 
wide enough to permit of the exposure of the most prominent part 
of the tumor. 

Operation. 

The surgeon may stand to the right side of the patient, or he may 
cause her to be placed near the end of the table nearest the light, 
with her limbs hanging over the end of the table, each foot resting on 
a stool, and take his position at the foot of the table. 

The operation may be divided into three stages, and the instruments 
necessary to perform it into as many groups. The first is the exposure 
of the tumor ; second, the removal of the same ; and third, the cleans- 
ing of the peritoneal cavity and closure of the wound. 

All instruments after thorough cleansing should be immersed in 3 
per cent solution of carbolic acid and taken from this by the operator 
as needed. 

For the first we need a scalpel, blunt-pointed bistoury, scissors, a 
grooved director, a sharp hook, and one or two sponges which have 
been thoroughly cleaned and soaked in water containing five per cent. 
of carbolic acid For the second and third, a large trocar with rub- 
ber tube, long and large enough to carry the fluid over the side of the 
patient down into a receptacle under the table : a large steel sound, 
scissors, forceps, and thread, with which to arrest hemorrhage; two 
large needles, armed with double-plaited silk ligatures, well waxed ; 
clamps, wire ecraseurs, and a half-dozen fine sponges that have never 



FIRST STEP. 763 

been in use, and thoroughly prepared by cleansing and carbolizing, 
and some pieces of fine soft flannel, one-half yard square; a half- 
dozen long, straight needles, armed with long silk ligatures, well 
waxed, and plenty of silk for tying small arteries ; lint, several rolls 
of cotton batting, and a binder of fine flannel, long enough and large 
enough to cover all of the dressings. In addition to these, there should 
be plenty of hot and cold water in basins, carbolized oil, and 
water. 

There should be at least three assistants : one to hold the rubber 
cloth and steady the tumor, who may stand at the side of the patient; 
another to administer the ether ; and a third to use the sponges and 
otherwise assist the operator. 

Before the patient is put under the influence of ether, she should 
empty the bladder ? and in default of her having done so, the catheter 
should be so used. 

The incision is usually made in the median line, midway between 
the umbilicus and the symphysis pubis. The cut through the integu- 
ment should be from two and a half to three inches long, and that 
through the subjoined aponeurosis and peritoneum only one inch in 
length. This is an exploratory incision, and will enable us to deter- 
mine the nature of the tumor, the extent and firmness of the adhesions, 
vascularity, etc., or whether there is a tumor or not. 

In making the incision we may cut freely through the skin and adi- 
pose tissue immediately beneath it. This will expose the aponeurotic 
expansion of the abdominal muscles. We now, with a sharp hook, 
lift up a thin layer of this aponeurosis and divide it. If we are not in 
the median line, the edge of the rectus muscle will come in view. 
When this is the case, we search for that line by passing the grooved 
director, or the handle of the scalpel, into the sheath, first to the right, 
then to the left, and the instrument will be arrested at the border of 
the muscle, and this points out the location of the linea alba. By 
very light strokes of the knife, or the lifting up of a portion of the ex- 
panded tendon, we carefully divide it down to a less marked, yet 
usually distinct layer of adipose tissue. This last is generally thin 
and loose compared with the subcutaneous stratum, and lies upon the 
peritoneum. It *should be carefully divided, and the peritoneum 
brought into view. Here the operator pauses until all hemorrhage 
ceases, and, if necessary, twists or ligates small arteries or veins which 
may bleed too freely. These steps in the operation, and in fact all 
others, should be taken without hurry, and the operator should give 
himself time to thoroughly understand the anatomy of the parts with 
which he is dealing. 

After the bleeding has ceased the peritoneum should be raised by 
the hook, and divided to an extent sufficient to pass the grooved 



761 ABDOMINAL OVARIOTOMY. 

director, upon which the division may be made to the extent of the 
deep portion of the incision. 

There are four sources of possible embarrassment in opening the 
peritoneal cavity. The first and most common is the adhesion of the 
parietal to the visceral layer of the peritoneum covering the tumor. 
This is more of an embarrassment than danger, as the only harm 
likely to be done may be the opening of the tumor. The next most 
frequent is the presence of the bladder between the tumor and the 
peritoneum, in which case it will require great care to prevent wound- 
ing this viscus. If there is any doubt which the appearance of the 
parts will not solve, it will be well for some one who is not assisting 
the operator to pass the catheter into that organ. When the bladder 
is found in this position it may be avoided by extending the incision 
upward sufficiently to pass above it. 

The third is the presence of the uterus beneath the incision. The 
use of the sound will enable us to diagnose this circumstance, if it 
has not been done in the examination before the operation. 

The fourth is the presentation of the intestine. We may diagnose 
this by the contents, shape, etc. 

When the peritoneum is divided sometimes ascitic fluid escapes, 
generally small in quantity, but sometimes copious. We should now 
inspect the exposed portion of the tumor. If it is an oligocyst, or 
monocyst, it will present a shining, pearly aspect, with very small 
vessels ramifying in its walls. If it belongs to the polycystic variety 
there will often be quite large vessels noticeable ; the pearly aspect 
will be less marked, and sometimes replaced by a livid or red color. 
If it is a uterine tumor it will be of a dull red color, thick and fleshy 
to the sense of touch. Tumors of the omentum, malignant or other- 
wise, would not answer to this description. 

Second Step. 

When satisfied that the tumor is ovarian, we should introduce the 
steel sound gently and slowly ; pass it over the anterior and lateral 
portions of the tumor, to ascertain whether there are any adhesions; 
if any, their locality and firmness. Often there will be some so very 
slight that they will give way as the sound is passed over the tumor. 

The force with which the sound should be applied to these ad- 
hesions must be very slight, as it is not advisable to break up strong 
adhesions in this way. 

Should there be no adhesions discoverable by the sound, the pre- 
sumption is that there are none. Upon this presumption our incision 
may be enlarged to the size of the tegumentary opening. 

If adhesions are large and firm, the whole incision should be in- 
creased until five inches in length. I believe this to be the proper 



SECOXD STEP. 



765 



time to extend the incision to its required length, because we may the 
better prevent the flow of blood into the peritoneal cavity. Up to 
this time the assistant who steadies the tumor has very little to do ; 
but, during the time of the enlargement of the incision and the 
removal of the tumor, he should keep the margins of the wound in 
such close apposition to the surface of the growth that nothing can 
enter the peritoneal cavity. 

Ovariotomy. 

The second step in the operation consists in the removal of the 
tumor. The large trocar, with a rubber tube attached, so as to lead 

Fig. 299. 




Fitch's Trocar. 

the fluid into a vessel under the table, may now be plunged into the 
cyst at the upper angle of the wound, and so much of the contents of 
the tumor as will pass through the tube be draAvn off. 

As the tumor decreases in size the sac should be seized by hooks, 
the trocar or forceps, or both, as may be necessary, and drawn for- 
ward in such manner that the opening in it will be outside the in- 
cision in the abdominal walls. 

In this way there will be less danger, if any, of the contents of the 
tumor escaping into the peritoneal cavity. 

This part of the operation may be very much facilitated by the 
assistant judiciously pressing upon the abdominal walls. When the 
fluid in the first sac is thus evacuated, another large cyst, if any 
should present itself, may be perforated by the trocar from the cavity 
of the main cyst, and still others consecutively until the tumor is 
small enough to pass through the incision. 



766 



ABDOMINAL OVAKIOTOMY. 



Should the secondary cysts be small or their contents so viscid as 
not to pass through the trocar, the opening in the main sac may be 
enlarged sufficiently to admit the ringers or hand with which the 
smaller cysts may be broken up, and their contents evacuated through 



Fig. 300. 




Trocar. 



the main opening. While the inside of the sac is thus manipulated, 
the margins of the opening should be drawn out beyond the lips of 
the external wound, and held so that no fluid can enter the abdominal 
cavity. Sometimes the whole of the contents of the tumor will be so 




Nelaton's Forceps. 

thick and tenacious that it will not pass through the trocar, when all 
of them may be removed by the hand in this way. 

When possible to break up the internal cysts with the fingers, the 
hand should not be introduced. In doing this part of the operation, 
great care should be taken not to rupture the parent cyst. 

As the tumor is collapsing we must look carefully for adhesions, 
and dispose of them as we meet with them. The omentum may be 
adherent to a part or the entire anterior surface of the tumor. 

If the omental adhesions are extensive they may be overcome by 
insinuating the fingers from above between the cyst and the omentum 



SECOND STEP. 767 

and carefully separating them. We should endeavor to do this with- 
out tearing any vessels except at their extremities. After the separa- 
tion we may turn this membrane back out of the wound, and allow 
it to remain there in care of an assistant until the tumor is removed. 
If it bleeds much, we may at once tie it as a whole or in sections, 
with fine silk, and return it into the abdomen. If the adhesions are 
small, we may lift the adherent portion up and ligate it en masse. 

I do not now think it necessary to cut ofT the ends of the omentum 
below the ligature, but return it all. In no case where I have done so 
has any disagreeable result followed. 

Adhesions to the abdominal wall may occupy but a small space or 
they may be quite extensive, and may be in front or at lateral portions 
of the parietes. 

Long broad fleshy bands sometimes extend from the abdominal 
walls and spread themselves over the front and sides of the tumor. 

These thick fleshy adhesions should always be ligated before they 
are separated from the tumor. 

If the flat adhesions of the surfaces are in front, we are often un- 
able to distinguish the peritoneum from other parts, and as a conse- 
quence the tumor is generally laid open in making the abdominal 
incision. The accidental opening is no disadvantage in such cases, as 
it enables us to evacuate the whole of the contents of the tumor, with- 
out the danger of having it flow into the peritoneal cavity. 

In this case the tumor must be evacuated before the adhesions are 
broken up. When the tumor is thus evacuated we may overcome the 
adhesions by introducing the hand into the empty cyst, seizing its 
walls and making traction from within, upon the points of adhesion, 
with sufficient force to cause .them to give way, and if there be no vis- 
ceral adhesions this is quite effective and safe. 

Another method is to extend the incision upward until the boun- 
dary of the adhesions is reached and passed a short distance, then we 
can carefully separate them by the fingers from above downward on 
the outside of the cyst. There is ordinarily some oozing of blood 
from the abraded surfaces, but the contractions of the abdominal 
walls usually arrest it ; if not we may cauterize the bleeding patches 
with the thermal cautery, take up the bloodvessels separately, and 
ligate them, or pass a curved needle, armed with thread, under the 
centre on each side of them, and by drawing the thread, thus surround- 
ing the patches, the surface will be puckered like the mouth of a 
purse, compressing the vessels sufficiently to arrest the hemorrhage; 
the thread may then be tied and cut off. In this way all danger 
from hemorrhage may be avoided. The long broad bands of adhe- 
sions may be tied in sections with fine thread and cut off close to 
the tumor. 

When it is necessary to introduce the hand into the peritoneal cavity, 



768 ABDOMINAL OVARIOTOMY. 

for any purpose during the operation, it must be thoroughly cleansed 
and dipped in carbolized water. 

As the tumor is being drawn slowly from the abdominal cavity, we 
should carefully watch for visceral adhesions. These should never be 
separated b} T traction, as above described, but the adherent portion of 
the cyst should be cut out with scissors, leaving a large margin attached 
to the viscera. 

To secure the patient against the danger of the secretions, which 
might eventuate from the surfaces of these abandoned pieces of cyst, 
the inner membrane should be stripped off by the fingers or forceps. 
In doing this we should retain firm hold on the parts by seizing the 
margins of the adhering patch of the cyst instead of the viscera. 

These directions are intended to apply particularly to visceral adhe- 
sions in the abdominal cavity, and are equally applicable to those 
within the pelvis, provided the adhesions are limited and may be easily 
reached and manipulated. Unfortunately, however, sometimes the 
tumor adheres with insurmountable firmness to the whole circle of the 
pelvic cavity, uterus, and bladder. In such cases I have no hesitancy 
in preferring enucleation, as taught by Professor Miner, of Buffalo. 
This may be done by cutting or tearing through the external layer of 
the cystic walls above the point of adhesion,and stripping it off from 
above downward into the pelvis, the fingers may be inserted between 
the outer and inner layers of the cj T st wall, until the latter, with the 
contents of the tumor, is removed. In this operation the vessels, 
arteries, and veins, which ramify in the connective tissue adherent to the 
peritoneal membrane, are not torn to any considerable extent, and are 
separated from the enucleated tumor. The tumor is turned out of its 
external envelope, the broad ligament is not injured or disturbed ; 
the tumor is removed from the ovary overlying that ligament. With- 
out a knowledge of its anatomy, seeing the tumor come out without 
any pedicle, is calculated to perplex us, and we can hardly believe in 
the completeness of the operation. 

The broad ligament, with the Fallopian tube, ovarian ligament, 
etc., contained within it, forms the pedicle, when the tumor is lifted 
out in the ordinary operation of ovariotomy, and the vessels pass 
through this to the connective tissue immediately beneath the perito- 
neum, covering the tumor. These are all left behind in enucleation. 

The vessels and peritoneal covering are left to contract by their 
own elasticity, and as they are not torn, except where the vessels are 
very small, they do not bleed much. If any vessels bleed after enu- 
cleation they may be ligated separately. 

After the adhesions are overcome and the contents of the tumor 
removed so that it may easily pass through the incision, gentle trac- 
tion will enable us to lift it from the abdominal cavity. One assist- 
ant may support the tumor in such a position that none of its con- 



THIRD STEP. 769 

tents will escape into the pelvic cavity and thus expose the pedicle 
without traction upon it. After carefully inspecting the pedicle and 
passing the fingers around and along the whole length of it 'to be as- 
sured that it is perfectly isolated, the operator may pass a large needle, 
armed with a double ligature of strong silk (the braided is the best), 
through the middle of the pedicle, an inch below the tumor, and 
ligate it very firmly on either side. The pedicle may then be divided 
with scissors close to the tumor. The division should be at least 
three-quarters of an inch from the ligature, and perhaps an inch would 
be better. 

If divided too near the ligature there is danger that by retraction 
the stump may be Avithdrawn from the loop and thus permit hemor- 
rhage to take place. 

We cannot be too careful in placing the ligature, tying it tightly, 
and leaving the stump sufficiently long. If this part of the operation 
is not properly done there is very great danger that the shock of vomit- 
ing will loosen the ligature and cause the death of the patient by sec- 
ondary hemorrhage. 

Before cutting through the pedicle it must be surrounded by a 
napkin at the ligated point to absorb the blood effused from the 
vessels of the tumor, and thus prevent it from passing into the peri- 
toneal cavity. 

Third Step. 

The third step in the operation consists in cleansing the abdominal 
cavity and dressing the wound. 

Before proceeding further the operator should examine the contents 
of the pelvis ; first, to ascertain whether there are any bleeding points, 

Fig. 302. 




Sponge Holder. 



and, secondly, to assure himself that the remaining ovary is sound and 
does not require to be removed. If the other ovary has commenced 
the process of cystic degeneration it ought also to be removed. 

If there have been adhesions, every point whence hemorrhage is 
likely to occur should be inspected and the hemorrhage checked by 
the means above mentioned. 

As the fluids — blood, serum, ovarian fluids, etc. — usually gravitate 

49 



770 ABDOMINAL OVARIOTOMY. 

into the pelvis, they may generally be cleaned away by carefully 
sponging that cavity. 

With the left hand passed into the pelvis the intestines may be 
lifted up and held out of the way, while with the right the operator 
gently and repeatedly presses the sponge down into the hollow of the 
sacrum, and thus takes up all the clots, fluid, blood, serum, etc. 
When this process is finished the abdominal cavity should again be 
inspected and thoroughly cleansed by the sponges, and before closing 
the wound the ligatures should be cut short, the uterus and stump of 
the pedicle be placed below the intestines in their normal position. I 
think this last precaution of properly replacing the pelvic viscera of 
much importance. 

I now close the incision with fine silk sutures about one-half inch 
apart, and passed in half an inch from the margin on the cutaneous 
surface so as to penetrate the fascia, peritoneum and muscle from the 
right, and penetrating the other side of the incision from within out- 
ward at similar points. When the incision is accurately closed I 
cover the wound with a piece of patent lint, saturated with carbolized 
oil, large enough to extend beyond the margins at least two inches in 
every direction. 

The wound thus covered is further protected by cotton batting five 
or six inches thick, which extends over the whole abdomen and down 
well upon the symphysis. 

The whole is secured by a flannel binder from the pubis to the ensi- 
form cartilage drawn very tightly. 

This dressing is not according to the Lister method, but I think it 
is quite as effective in keeping out septic particles. 

I have given the reader in detail the method of operating which I 
now employ. Like most other gynecologists who have practiced 
ovariotomy since 1859, I have performed the operation in many dif- 
ferent ways, but for several years I have operated uniformly in the 
manner above described. Every step in the operation, as I now per- 
form it, is done in the simplest possible way, and this I think a great 
recommendation. 

I would impress upon my readers the great importance of gentle- 
ness of manipulation. We should not forget, in the excitement of the 
operation, that we are handling the abdominal organs, and plunge our 
hands roughly and forcibly into the peritoneal cavity, search for ad- 
hesions, and tear them away violently, heedless of the damage thus 
inflicted. 

I would not think it necessary to so implicitly insist upon gentle- 
ness, if I had not, on more than one occasion, seen the peritoneal 
cavity, with its contents, submitted to such violence. 

It is only necessary further to say that all the sponges used should 
be new and thoroughly carbolized. 



CHAPTER XLVI. 

OVARIOTOMY (Continued). 

Accidents that may occur during the Operation. 

Unfortunately in some cases of ovarian tumors, the adhesions are 
so extensive and intricate, and the cysts so changed by deposits of 
albuminous and fibrinous accretions, that the anatomy of the growth 
and surrounding organs is confused beyond recognition. The rela- 
tions of the viscera and tumor sometimes are so unusual, and so con- 
trary to all precedent observation, that the experienced operator is 
sometimes betrayed into mistakes and accidents of a very grave char- 
acter. It will not be out of place, therefore, to warn the young prac- 
titioner of what may happen, and what is the best way of managing 
accidents that may occur. 

When the anterior portion of the cyst is generally and very firmly 
adherent to the peritoneum of the abdominal wall, the inexperienced 
operator will sometimes find himself separating the peritoneum from 
its natural attachments, under the impression that he is breaking up 
adhesions. There are probably very few of us who have not com- 
mitted this mistake to a greater or less extent. This may generally 
be avoided by making the incision long enough to carry the opening 
above the point of adhesion, and then separating it from above. We 
may recognize the accident in its incipiency by turning the lip of the 
wound strongly outward, and inspecting the inner surface of the ab- 
dominal wall. 

The absence of any but the fascial covering of the muscles will at 
once set us right. If, however, the peritoneum should be separated, 
it is of much less importance than we would expect. In one instance 
I saAV several inches of that membrane entirely removed without 
affecting the speedy and perfect recovery of the patient. 

Should this accident occur unwittingly, or in spite of our precautions, 
the membrane should still be separated from the tumor with as little 
injury as possible, and when we come to close the incision the interval 
between the membrane and the muscles should be thoroughly cleansed, 
the peritoneum smoothly applied to its natural surface, and included 
in the stitches with which the wound is drawn together. If the 
membrane is so mutilated that we are in great doubt as to the integrity 
of its structure the worst part may be cut off and removed. 

During incautious separation of adhesions to the liver, spleen, or 
kidneys, these organs may be wounded. If the surface thus injured 



772 OVARIOTOMY. 

does not bleed, we cannot do better, perhaps, than let them entirely 
alone. If, however, hemorrhage results from the accident and the 
surface is small, we may surround the bleeding space by a fine silk 
ligature, in the manner already directed for similar places in the ab- 
dominal wall. If the surface is so large, however, as to make this 
impracticable, the actual cautery should be used for the purpose of 
closing the vessels. If the pelvic portion of the kidney is torn so 
that the urine flows from it into the abdominal cavity, nothing is 
left for us to do but to extirpate the injured organ. I know of no 
precedent for this method of managing such a case, but in view of 
the fact that one kidney has been removed for other conditions with- 
out fatal results, I would not hesitate to give my patient the benefit of 
the operation. 

Wounds in the intestinal canal, including the stomach, when there 
is no loss of substance, should be carefully closed with fine silk sutures. 
In closing such openings the stitches should be very near together to 
prevent the escape of fasces. It is also important that the edges 
should be smoothly coaptated, and the mucous membrane pressed into 
the tube to make sure that it does not intervene between the lacerated 
or cut edges of the wound. After an operation attended with this 
accident the peristaltic movement of the bowels should be quieted by 
a liberal and continued administration of opiates for at least ten days. 
The diet should be liquid, and probably beef soup, or beef essence 
would be the best. 

By far the most difficult accident (and yet it would seem not alto- 
gether desperate to manage) is the wounding of the urinary bladder, 
the gall-bladder, or ureter. When the gall-bladder is wounded the 
onl} r way that we could hope to secure any chance of escape would be 
to stitch it into the wound, — and if necessary the wound should be 
sufficiently elongated, — to insure a temporary discharge of the bile 
external^. Of course a perfect cleansing of the abdominal cavity of 
all that fluid, would be indispensable to the avoidance of inflammation 
from its irritating qualities. 

With reference to the lesion of the urinary organs I subjoin an ab- 
stract of a paper read at a meeting of the French Society for the 
Advancement of Science, by Dr. G. Eustache, of Lille (Arch, de Tocol, 
April and May, 1880).* 

"Since such wounds are inflicted only in very complicated cases, when there exists 
widespread, resisting, and vascular adhesions, and when a protracted operation is thus 
rendered additionally difficult by the more or less prolonged contact of urine with the 
peritoneum and lips of the wound, they will indeed become a serious complication. 
This, especially, because the already exhausted condition of the patient warrants per se 
a bad prognosis. Such at least is the generally accepted opinion. Now, Eustache, 

* American Journal of Obstetrics, January, 1881. 



ACCIDENTS THAT MAY OCCUR DURING THE OPERATION. 773 

in his last ovariotomy, had the misfortune to make a large wound of the bladder, but 
the patient speedily recovered, notwithstanding that the urine had abundantly flowed 
into the abdominal cavity for over an hour. This occurrence suggested to him the 
idea that the prognosis in similar cases might be better than was generally admitted, 
and, provided adequate therapeutic measures were instantly adopted, might in future 
be still ameliorated. Accordingly, the literature of the subject was studied, but the 
information thus gained was almost nil. The writer, therefore, communicated per- 
sonally with many of the leading ovariotomists, and the answers he received tended to 
confirm his previous opinion. He then proceeded to communicate what he had thus 
gleaned, and supplements the whole by an analysis of known cases. 

" Kenal lesions are in the first place considered. The case of Spencer Wells is cited, 
in which a firmly adherent kidney was removed along with the ovarian tumor, the 
patient dying soon after. Three other cases, all instances of erroneous diagnosis, are 
cited. From the records of these cases, no conclusion can be drawn. Lesions of the 
ureters are next examined. Three cases where one ureter only was wounded are 
given. In each the patient was cured without even the leaving of an urinary fistula. 
All these occurred in Germany. The author was unable to find similar instances in 
the records of the French and English surgeons." 

Finally, vesical lesions are disposed of, and the author refers to an 
interesting personal observation elsewhere fully described (Arch, de 
Tocol, July, 1879). Dr. Eustache concludes as follows : 

" 1st. Lesions of the urinary organs during ovariotomy are very rare. 

" 2d. Wounds of the kidney followed by extirpation, proved fatal in the only case 
on record. 

" 3d. Lesion of the ureters was in every case followed by a cure. 

"4th. Vesical lesions were more frequently followed by a cure than otherwise. 

"5th. When the ureter is divided it should be immediately united by sutures. 
Should this prove to be an impossibility, the upper end of the ureter should be secured 
in the walls of the bladder. If a uretro-abdominal fistula supervenes, an artificial pas- 
sage, going from the fistula to the bladder, should be established. 

" 6th. If the bladder has been opened during an operation, it should be immediately 
sewed up with carbolized catgut, and a self-retaining catheter introduced. 

"7th. If the vesical opening occurs posteriorly (in the vagina), the catheter and 
several cauterizations will suffice to establish a cure. 

" 8th. In all cases of this kind subsequent treatment must be cautiously carried out. 

" 9th. Antiseptic dressings generally assure success." 



CHAPTEE XLVIL 

OVARIOTOMY (Continued). 

After- Treatment. 

At the close of the operation it will often be found that the clothing 
and person of the patient have become soiled, and it will be necessary 
to cleanse her and change the clothing. If the patient is strong, and 
there are no evidences of nervous depression or shock, this may be 
thoroughly but carefully done, and the patient placed in bed. If, 
however, she is cold, and the pulse is weak and quick, and other signs 
of exhaustion show themselves, we would add to her peril by too 
much attention of this kind. When we do not deem it best to remove 
the clothing at once, we should carbolize the soiled places and place 
dry woollen cloths between them and the skin to protect the patient 
from the chilling effects of the dampness. Bottles of warm water 
should be placed about her feet and limbs, and, in marked cases of 
shock, around the body also. 

The question of administering stimulants must be decided by the 
conditions of the patient, the temperature of the surface, and the 
character of the pulse. If reaction does not take place readily under 
the influence of the warmth and covering, they should be resorted to 
very soon, and may be given by the stomach or rectum, or hypoder- 
mically. Brandy is generally the best stimulant, but carbonate of 
ammonia or chloroform may be given until reaction is established. 
As the patient recovers from the influence of the anaesthetic, she will 
generally complain of pain, and will require an anodyne, which should 
be administered without delay in quantities proportionate to the pain. 
The anodyne may be repeated at such intervals and in such doses as 
are necessary to keep the patient free from pain, and no more. 

The room should be darkened, but the windows so arranged as to 
admit an abundance of fresh air. If the weather is cold, the tempera- 
ture ought to be maintained by an open grate, if possible, and not 
above sixty degrees (F.). 

Another thing which I think should be insisted upon is, that the 
abdominal muscles be kept in a state of complete rest, by rigid con- 
finement to the dorsal position, until all danger of traumatic perito- 
nitis has passed, that is, for the first four or five days. In general, 
this position will not be very fatiguing if the influence of the ano- 
dyne is maintained to a proper degree. The evacuation of the bladder 
by the use of the catheter w T ill be one of the means of promoting 
absolute rest. 



ATTENTION TO THE CLOTHING. 775 

The more fortunate cases will require no other treatment, and by 
good nursing will pass through the convalescence without much in- 
convenience. 

Treatment of the Wound. 

Unless something unusual occurs, such as discharge from, or pain 
in the wound, it need not be dressed until the fourth or fifth day. 
The cotton batting and oiled lint may then be removed, and if the 
wound requires no particular attention, both may be replaced by fresh 
material. Generally we will find no signs of inflammation or puru- 
lent discharge, everything looking fresh and solid. The dressing 
should be removed again on the sixth or seventh day, if suppuration 
or some kind of discharge does not render it necessary sooner, and at 
this time the stitches may be taken out, the wound cleansed with car- 
bolized water, and dressed with adhesive straps so as to give support 
to the abdominal walls. A narrow strip of lint, saturated with car- 
bolized oil, should then be placed over the straps and the wound, 
where they cross it. From this time forward the dressing should be 
examined and attended to every second day, and, if need be, every 
da}' until consolidation is complete, which, when everything goes on 
well, will be in from fourteen to twenty daj^s. During all of this 
time, and for two or three weeks longer, the binder and cotton should 
be continued, the latter gradually made thinner at each dressing until 
it can be omitted. 

Attention to the Clothing. 

When it is possible to put the patient to bed with her clothes clean 
and dry, every care should be taken to keep them so, and no change 
made until the fourth day. After that time, changes can be made 
as often as necessary to preserve cleanliness. It is often difficult, 
when a patient is very weak, to determine how much we may do to- 
ward removing soiled clothing. Remembering that the exertion is 
a cause of further prostration, and that soiled clothing is a source of 
sepsis, the practitioner will be compelled to decide how much the 
patient can bear, and personally supervise all attempts at changing 
the clothing and bed. If it is deemed improper to remove the gar- 
ments which have become soiled, we can do much to avert the dele- 
terious effects, which might otherwise occur, by using carbolic acid 
freely upon the soiled portions, and placing dry woollen cloths next 
the patient. 

There are two symptoms so frequently met with after ovariotomy, 
apart from any dangerous pathological conditions, that they ought to 
be considered before studying the graver difficulties. While they are 
often not the result of, nor accompanied by, septic fever, nor other of 
the more fatal consequences of ovariotomy, yet, if not arrested or 



776 OVARIOTOMY. 

properly managed, they may, and sometimes do, lead to a fatal ter- 
mination. I allude to vomiting and tympanites. 

Vomiting. 

In many instances troublesome nausea and vomiting occur imme- 
diately after the operation. When this is the case it is generally the 
effect of the ansesthetic upon the nerve centres, and it is attended with 
vertigo, and more or less headache. Cold applications to the head 
and a hot water bag to the back of the neck, together with hot brandy 
and water, in small quantities internally, will generally relieve it. 

A hypodermic injection of morphia and atropia, given at the time 
or soon after the operation is finished, will often relieve both the 
pain and vomiting. Sometimes this symptom, arising from this 
cause, will continue for two or three days, and gradually subside; 
and, when it resists appropriate remedies for twenty-four hours, it 
would be as well to not medicate the patient much. 

When vomiting is caused by the secondary effects of opium, or some 
of its preparations, it is apt to come on the second or third day. The 
opium completely arrests digestion, and the ingesta undergoes chem- 
ical decomposition, and the materials thrown up are very sour, and 
have a grass-green appearance. The patient is pale, cool, and quiet, 
though not stupid. The pulse is not changed, except, perhaps, weak- 
ened. The urine scanty, and ordinarily there is an abundant precipi- 
tate. This is usually a troublesome form of vomiting, and is benefited 
most by stimulants, as "champagne and very strong coffee in small 
quantities. Carbonate of ammonia is often very useful. While the 
patient is fully under the influence of the opiate, the vomiting is 
moderated, if not entirely controlled ; and it is sometimes a question 
whether we continue or withdraw the opium. When pain, septic 
fever, or other such indications exist, I would not hesitate to keep the 
patient under the influence of opium sufficiently to relieve the pain 
and vomiting together by hypodermic administration, or the use of 
suppositories containing morphia. 

The forms of vomiting here mentioned are sometimes so obstinate 
as to make it impossible to administer medicine or nourishment by 
the stomach ; and we often protract the suffering of our patient by 
vain attempts to do so. Generally it will be better practice to ad- 
minister all of these by the rectum and by hypodermic injections, and 
allow the stomach complete rest. 

Rectal administrations are so efficacious, when well managed, that 
a patient may be sustained by them for many days. 

Dr. Henry J. Campbell,* of Augusta, Georgia, by some interesting 

* In Gynecological Transactions. 



TYMPANITES. 777 

experiments, has enabled us to understand why food may be com- 
pletely digested when administered per rectum. 

He found that the milk he injected into the rectum of a calf made 
its way up into the small intestines, where it could be mixed with the 
digestive fluids. Milk, eggs, beef essence, finely chopped beef, and 
perhaps other forms of animal food in small quantities, may be re- 
tained and digested in sufficient amounts to sustain the patient until 
the stomach will regain its power of retention. 

Tympanites. 

Until the antiseptic method of conducting surgical operations was 
applied to ovariotomy, tympanites was of very much more common 
occurrence than now. Dr. Peaslee* says : 

" Some degree of tympanites usually occurs, even in the simplest cases, on the second 
or third day after ovariotomy, on account of the diminished contractility of the ali- 
mentary canal, and in such cases it subsides in the course of four or five days under 
the simplest treatment." 

The conditions which usually give rise to the more obstinate forms, 
when not a complication of general traumatic or septic peritonitis, 
according to Dr. Peaslee, is atony of the intestinal canal, spasmodic 
condition of the sphincter ani, obstruction of the canal by fecal accu- 
mulations, twisting of a convolution of the small intestine, and me- 
chanical obstruction external to the alimentary canal itself. 

Tympanites from the first of these causes- occurs as often as before 
the use of antiseptics. 

Where we have to deal with the second condition a rectal tube in- 
troduced and kept in the rectum will, sometimes, be sufficient to re- 
lieve it. 

The third cause of tympanites is more difficult to diagnose and also 
to manage. If the alimentary canal is well evacuated before the op- 
eration this form will not often occur. When we believe this to be 
the cause it will be operative only when in connection with atony of 
the muscles of the alimentary canal, and may be best relieved by 
stimulating enemata through a long tube, faradization, as practiced 
by Dr. Anthony on one of Mr. Well's patients, by a tight binder, a 
roller around the abdomen, and, if the stomach is not irritable, by the 
administration of piperine, extract of nux vomica, and belladonna. 
For the fourth variety, or twisting of the alimentary tube, and the 
fifth, obstructions from mechanical causes outside the alimentary 
canal, our resources are very limited, and the means of relief haz- 
ardous. 

* Ovarian Tumors. 



778 OVARIOTOMY. 

These means are the knee-chest position and injections of large 
quantities of hot water, puncture of the intestinal tuhe with the 
smallest aspirating needle and opening the wound, thus correcting 
the twisted condition or dislodging the canal from any confinement 
in which it may be placed. 

In continuation of the subject of after-treatment of ovariotomy 
we must consider the more grave accidents and conditions to be met 
with. 

How do these patients usually die ? 1st, by shock and collapse ; 
2d, hemorrhage; 3d, acute (traumatic) peritonitis; 4th, septicaemia, 
complicated or not, with tympanites. 

Shock or nervous depression is almost always manifested at the 
close of the operation, and is marked by paleness of the surface, 
feebleness, and generally quickness of the pulse, with great languor, 
and sometimes entire inability to move. The nervous depression 
passes into exhaustion, and death, in some instances, follows within a 
few hours; while in other cases the patient may linger in a state of 
depression for three or four days, and then die from no apparent 
cause except the continuation of the shock. 

In the most profound cases of shock we should apply dry heat ex- 
ternally to as great a degree as the patient can bear, and keep her 
as still as possible, remembering that every movement adds to the ex- 
haustion. The heat may be applied by a large number of hot bricks, 
stones, and irons. 

They should be applied the whole length of the patient, to the feet, 
legs, trunk, arms, shoulders, and head, and at the same time the tem- 
perature of the room should be raised. Applications of heat to the 
head is of more importance probably than anywhere else, for stimu- 
lating the brain will often arouse the whole nervous system and dispel 
the symptoms. 

The most effective way to do this is by using the rubber coil and 
passing hot water through it instead of cold. Plenty of warm covering 
will be necessary, of course, and if the stomach is not irritable the 
patient should drink as much hot water as she can. I am quite sure 
that the vigorous application of heat in this way is much more effec- 
tive than alcoholic or other medical stimulants. These, however, may 
be added and administered by the stomach, rectum, or hypodermically. 
If the depression succeeding the shock should last and be threatening 
in degree the heat should be continued; nourishment and internal 
stimulants administered perseveringly until reaction is established. 

Hemorrhage 

Is said to proceed from the following different sources : 1st. From 
the pedicle in consequence of the imperfect application of the ligature, 



TRAUMATIC PERITONITIS. 779 

or the retraction of the tissues included in its grasp, so that it becomes 
loosened. 2d. From wounded surfaces left by the separation of ad- 
hesions. This last is not often fatal as a hemorrhage, but it may 
become so in rare instances. The blood derived from this source is 
however apt to decompose and cause septicaemia. 3d. From rupture 
of a plexus of veins near the ligature or elsewhere in the pelvis. Dr. 
Peaslee lost a patient from hemorrhage, and on a post-mortem exami- 
nation found that it proceeded from this source. He also speaks of 
others. 4th. In certain conditions of the blood predisposing to hem- 
orrhage, the blood from the inner portion of the incision finds its way 
into the abdominal cavity in considerable quantities. 

I met with an instance where hemorrhage from the wound im- 
mediately under the skin, the blood escaping outside, gave me a great 
deal of trouble. In this case the blood was so changed that coagu- 
lation did not occur after standing ten hours, and astringents locally 
applied failed to stop the hemorrhage, and the only way it was arrested 
was by putting pins through the lips of the wound half an inch apart 
and plugging the wound tightly in the interspaces. 5th. From an 
artery perforated by a needle used in closing the wound (Wells). 6th. 
From the patulous extremity of the Fallopian tube. 

In all of these conditions hemorrhage may follow the operation im- 
mediately or occur any time during the convalescence. Succussion 
from coughing, straining to vomit, moving about too much, mental 
excitement, may all contribute to start up hemorrhage when the pre- 
disposing conditions exist. When the hemorrhage takes place from 
the pedicle or ruptured veins, the symptoms generally appear sud- 
denly and are marked in character. They need not be enumerated 
here ; but where the hemorrhage goes on slowly from abraded surfaces 
the symptoms are sometimes very obscure. Increasing rapidity and 
weakness of the pulse, paleness of the face, coldness of the extremities, 
profuse perspiration, nausea, and vomiting coming on any time after 
the first twelve hours, when not preceded by evidence of shock, are 
symptoms which point strongly to this accident. 

When the symptoms of hemorrhage become marked, there is but 
one sure way of giving the patient a chance for her life, and that is, 
to open the wound, explore for the source of the hemorrhage, and 
ligate the vessels or bleeding points when found. The abdomen 
should be very carefully cleansed of the blood. 

Traumatic Peritonitis. 

Peritonitis, caused hy opening the abdomen, judging from my own 
observations, as well as the reports of others, is not very common, and 
has become less so since the antiseptic methods have come into gen- 
eral use. At a time when our experience was small, compared with 
what it now is, this was the most feared of all the consequences of the 



780 OVARIOTOMY. 

operation. This fear was founded upon the well-known fact of the 
fatality resulting from accidental peritoneal wounds. 

Fortunately we now know that the susceptibility of the peritoneum 
has been very much overrated, and also that in cases requiring ovari- 
otomy, it has lost much of the tendency to inflammation which it 
possesses in a healthy condition. The long-continued distension, 
friction, and frequent inflammations, to which it has been subjected, 
so modify its structure as to greatly alter its appearances, and in almost 
all instances to reduce its tendency to inflammatory processes very 
much. Hence we expect oftentimes to escape this very dangerous 
affection. When it does come, it makes its appearance within the 
forty-eight hours immediately succeeding the operation. Its symp- 
toms are pain, tenderness, and tumefaction of the lower part of the 
abdomen, frequent pulse, and elevation of the temperature. In unfa- 
vorable cases these symptoms rapidly increase until the abdomen is 
largely distended and very tender ; the pulse rises to 130 to 150, or 
even 160; the heat increases as high as 106 degrees. Mental dis- 
turbances become a prominent feature toward the close. These cases 
often run their course to a fatal termination in two or three days from 
the beginning. The temperature and the pulse are the best guides to 
the intensity of the inflammation. When the former does not rise 
above 103 degrees-, and the latter above 120 per minute, we may have 
a reasonable hope of recovery. 

The objects in the treatment of this form of peritonitis are to curb 
vascular excitement, reduce the temperature, and control pain. Opium 
in large doses, commenced at once and continued to deep narcotism, 
will go a great way toward accomplishing all of these objects, I be- 
lieve that this treatment, at the very inception, will sometimes at once 
break the force of the attack. After the first forty-eight hours, or even 
sooner, large doses of quinine may be added to the opiate treatment, 
when the opium should be slowly withdrawn and brandy substituted 
for it. The quinine, however, should be continued. 

These remedies, quinine and brandy, arrest the waste which follows 
the first stage. With these, nourishment should be pushed to the 
capacity of the stomach and rectum. When there is vomiting, these 
remedies may be given hypodermically and per rectum. Ice and 
ice-cold water may be allowed as desired, according to the craving of 
the patient. Thornton's cap will be of great service in these cases 
also, as the cold water circulating through it will greatly reduce the 
general temperature. A question of great importance is, What ap- 
plications shall be made to the abdomen ? In the first two days, if 
the temperature is high, I should have no hesitancy in applying cold 
by means of the water-bag ; but I should promptly change from this 
to warm applications after the stage of effusion had passed, about 
the third day of the disease. 



SEPTICEMIA. 781 



Septicaemia. 



This is another of the formidable and fatal sequences of ovariotomy. 
As the operation is now performed, — that is, with antiseptic precau- 
tions, — it may generally be avoided. 

The most common cause of septicaemia is the retention, decompo- 
sition, and absorption of fluids from the tumor, or from extravasated 
blood. The observations of numerous operators have established the 
fact that the retention of these fluids does not always result in septic 
fever, because they do not always undergo decomposition; especially 
is this the case, as before intimated, if the antiseptic precautions have 
been faithfully and sufficiently carried out. When it does occur, it 
may follow the reaction which succeeds the protracted depression of 
shock ; but when not occurring in this way, it comes on in from four 
to seven, and even ten, days after the operation. Its course is vari- 
able, terminating sometimes in five or six days, especially when com- 
plicated, and this, I think, rather a frequent thing with peritonitis ; 
while in the simple form it may last for ten or twenty days, or even 
longer, before wearing the patient out or merging into convalescence. 

The prognosis, although bad, is not absolutely desperate. Some- 
times the attack is sudden, inaugurated by a chill, and succeeded by 
a rise of temperature and accelerated pulse ; or it may be established 
in a very gradual manner, the pulse and temperature rising slowly. 
They are generally both much higher in the after-part of the day. 
Derangement of particular organs is not uniform. The skin, some- 
times dry and hot, is often bathed in a copious perspiration, the per- 
spired fluid being sometimes very thin and watery, and again quite 
viscid and sticky. The stomach may or may not be disturbed, but 
generally the rest of the alimentary canal is more or less irritated, and 
diarrhoea, with profuse, thin, stinking stools, is often a marked feature 
of septicaemia. Nervous excitement and delirium, or somnolence and 
apathy, form part of the symptoms in different cases. In many 
instances great tympanites, with or without peritonitis, add to this 
mischief. In the course of the disease, the circulating fluid some- 
times becomes decomposed to such an extent as to pass easily out of 
the capillaries, giving rise to maculae, blebs, and bullae, or appearing 
in the urine or dejecta from the bowels, or exuding from the exposed 
mucous membrane in the mouth or nostrils. More frequently, how- 
ever, the disease runs its course rapidly when a very quick pulse, 
from 120 upward, high temperature, from 104 degrees upward, de- 
lirium, excitement, or somnolence, and apathy constitute the impor- 
tant and noticeable symptoms. In either the slow or rapid case the 
stomach will not digest the food taken, and the lacteals will not 
absorb the material exposed to their action. Sanguification is ar- 
rested, and the scorching temperature is maintained by combustion 



782 OVARIOTOMY. 

of the material in the blood, which ought to sustain the vital func- 
tions. The patient is soon exhausted under this rapid waste, being 
incapable of appropriating anything with which to supply the de- 
ficiency. 

Treatment. 

The most important item in the treatment of septicaemia arising 
after ovariotomy is to remove the cause. This, as has already been 
said, is decomposing substances in the peritoneal cavity. In almost 
all cases the decomposing substances, serum, blood, etc., gravitate to 
the bottom of the cul-de-sac of Douglas, where we can reach it. The 
fluid can usually be detected per vaginam, but sometimes the quan- 
tity is so small as not to be appreciable by such an examination. In 
either case we should open the peritoneal cavity through the vagina, 
introduce a drainage-tube, and wash out the pelvic cavity with warm 
water. We may open the peritoneal cavity by means of scissors. 
The patient may be turned upon her side, Sims's speculum intro- 
duced, and the posterior wall of the vagina lifted up by a hook and 
perforated. The opening in the vagina should be in the median line 
as nearly as possible. The incision should be large enough to admit 
a good-sized tube. Through this the fluid will escape, and we may 
throw water into the pelvis. We may also perforate the posterior 
vaginal wall with a trocar. This may be done very easily when the 
quantity of fluid is considerable and the retrouterine pouch well dis- 
tended. If opened in this way the first washing may be done through 
the canula before it is withdrawn, after which a tube should be passed 
through the canula, and as the latter is withdrawn the former is re- 
tained, or we may remove the two lower stitches and introduce the 
drainage-tube through the lower end of the wound. 

The cleansing of the abdominal cavity will require repetition in 
proportion to the amount of decomposing materials. Of course no 
one would think of performing this operation until septic fever is 
evident. When this is the case the risk of evacuating the fluid and 
cleansing the pelvic cavity ought certainly to be considered a neces- 
sity, and when indicated it is worth more than all the remedies we 
can bring to bear in the treatment. The rest of the treatment has for 
its object the relief of symptoms, preventing waste, and introducing 
as much nourishment as can be borne by the stomach, rectum, or 
both, and hypodermically. 

Probably the most important symptom to be attended to is the 
high temperature. This may be combated by cold externally ap- 
plied or administered internally. Cold can be very effectually ap- 
plied to the head by means of the ice-cap invented by Mr. Thornton, 
of the Samaritan Hospital. It is very highly recommended by Mr. 
Wells. It is a coil of rubber tubing so arranged as to fit the head like 



REMARKS. 



'83 



a cap, and when applied to the head the tube is filled with ice-water, 
and one end is placed in a bucket of ice-water very slightly elevated 
above the head of the patient, while the other end is passed into a 
tub under the bed or elsewhere. 

By elevating and depressing the two ends of the tube the water 
may be made to run more or less swiftly through the portion forming 
the cap as we may desire. If this cap cannot be commanded, india- 
rubber bags or coils filled with ice-water, or a large beef's bladder, or 
ice inclosed in rubber cloth or oiled silk may be substituted. 

Cold may thus be applied with sufficient intensity to lessen the 
heat of the entire body in a very short time, and I think is very 



Fig. 304. 




Rubber Coil. 

much to be preferred to any general application of cold however 
made. 

Quinine and antipyrin administered in large quantities are very 
efficient in reducing temperature and preventing waste; so also is 
alcohol. Five grains of quinine every four hours, or ten grains every 
eight hours, or a like amount of antipyrin, is the proper dose. Brandy 
in ounce doses every two hours may be given for a like purpose. If 
tympanites or peritonitis, or both, complicate the fever, there are local 
means for their treatment, as elsewhere detailed. 



Remarks. 

I am among those who believe in antiseptic surgery. My opera- 
tions date back to 1861, when everything in connection with ovari- 
otomy was in an unsettled state. It is true that there is not perfect 
accord among ovariotomists at the present time, but we have had a 
great deal of experience in different methods of procedure, in the 
several steps of the operation and after-treatment, and can conse- 
quently more intelligently estimate them ; and I think it safe to say 



7>4 OVABIOTOMY. 

that the antiseptic process has about done away with the clamp and 
primary drainage. 

My : evictions as to the benefit of the antiseptic processes in ovari- 
otomy are grounded upon my own experience more than general 
statistics, although I think the latter are sufficiently convincing. 

While there has been a very marked change for the better since 
adopting the antiseptic method. I think my mind has been influenced 
in coming to a conclusion favoring antiseptic practice by the appear- 
ance of the wound. S ::■ i as :he wound is concerned there is no ques- 
tion about the effects of the dressing. When properly managed there 
is no smell, no pus. and no ulceration. It heals without any evidence 
of decreased vitality in the part. In expressing my belief in the 
efficacy of antiseptic processes in surgery I do not announce any 
opinion of th- ; operandi. I am not sure that there are septic 

particles that fall upon and induce ferment in the wounded parts, : 
living germs' or ova that infest, breed, and diffuse themselves in such 
numbers as to lesti y the vitality of the points of attack, and gaining 
access to the vessels disintegrate the circulating fluid so that it is not 
fit to support the vital forces, and that the _ die acid operates by 
consuming these deleterious particles. But I do believe that it adds 
greatly to our means of avoiding one if not more of the untoward 
conditions sometii : - exj { fter ovariotomy. 

J nor of the Broad L Iga ment, or P< T- nor. 

This tumor has its origin in the minute serous canals situated in 
the broad ligament between the outer extremity of the Fallopian tube 
and the ovary. Although small they are easily seen by holding the 
part between the eye and a bright light. The fluid occupying these 
tubes is simple serum. The tumor seems to consist of the great hy- 
pertrophy and distension of these canals from hypersecretion of the 
natural fluid contained in them. The tumor thus occasioned - me- 
times grows very large. While usually not so great in size, occa- 
sionally they grow sufficiently to cause listressing distension of the 
abdomen. They always assume the form of a single cyst. The 
anatomy of this cyst is very simple. It is lined by a delicate serous 
membrane and covered by the peritoneum. These two membranes 
gethei by connective tissue and form a frail connection 

tween them. These are the essential anatomical elements of the 
tumor. But often, as they grow large the fibrous tissue of the bi 

at is - : ried up with the increasing tumor, covering the cyst up- 
ward for some distance. The fibres of this covering are sometime- - 
abundantly increase is to form large flesl ndssfa itching in every 

direction around the base : the tumor. Sometimes this envelope is 
hardly noticeable :■: ttl ttom of the growth. 



PAROVARIAN TUMOR — SYMPTOMS. 785 

The parovarian tumor is meagrely supplied with blood, hence their 
usual slow growth. The bloodvessels are found in the fibrous cover- 
ing and consist of many small arteries and veins, running up from 
the broad ligament. No large arterial trunk, such as is found passing 
through the pedicle of an ovarian tumor, belongs to the system of 
vessels supplying this growth. 

This arrangement makes it easy to enucleate the tumor by care- 
fully stripping off the fibrous covering containing the vessels. When 
properly done this operation is seldom followed by any considerable 
loss of blood. 

Occasionally, instead of the broad ligament tissues growing up with 
and on the tumor, this latter seems to spring from the surface of the 
ligament ; thus presenting sufficient pedicle to ligate safely. 

The microscopy and chemistry of the fluid contents of the parova- 
rian tumor are not very marked. They prove it to be very pure 
serum. Under the influence of inflammation or violence the serum 
may be very much modified by the addition of the products of those 
conditions, hence come pus corpuscles, a more or less abundant sup- 
ply of albumen and blood globules. 

Etiology. 

The time of life in which this tumor shows itself is the same as 
that usually occupied b}^ ovarian cystomata, viz., from puberty to the 
menopause. It is comparatively rare. From my own observation, I 
should say it occurred in about six per cent, of the cysts springing 
from the ovarian region. The cause of the parovarian tumor is not 
obvious ; but consists of some influence that increases the secretion of 
the natural fluid of the parovarium, or prevents the absorption of it. 

Symptoms. 

There are no subjective symptoms announcing this growth until it 
is large enough to cause inconvenient pressure. As the growth is very 
slow, inconvenience from pressure occurs late. Sometimes after attain- 
ing considerable bulk their thin wall gives way and the fluid is evacu- 
ated from the cyst and emptied into the peritoneal cavity. As a 
consequence of this accident in some instances the tumor disappears, 
the fluid is absorbed and the patient is well. More frequently, how- 
ever, the fluid reaccumulates. 

The rupture of the cyst and the discharge of its contents into the 
peritoneal cavity gives rise to sharp pain and slight shock succeeded 
by moderate febrile reaction and collapse of the abdominal tumefac- 
tion. The symptoms generally disappear in a few days and the 
patient considers herself well, to be disappointed by the reappearance 
of the tumor. 

50 



786 



OVARIOTOMY. 



Diagnosis. 

To make a clear differential diagnosis between broad ligament and 
ovarian tumors, is not always possible without tapping or exploratory 
incision. But the following are some of the more obvious points 
of difference between them. The ovarian tumor is seldom mono- 
cystic, that of the broad ligament is generally so. The ovarian tumor 
is filled to great tenseness, and the cyst wall is thick and strong, mak- 
ing distinct resistance to pressure ; the parovarian tumor is not usually 
so tense and resistent to pressure. The wall is so thin and often so 
flaccid as to permit of visibly undulating fluctuation. It is generally 
quite globular and symmetrical in shape, while the ovarian tumor 
usually presents some unevenness of surface and the fluctuation is not 
the same in every direction, some places having more than others. 
The fluctuation in the parovarian tumor is the same from all points, 
and in the greater the same as the smaller distances. In small sized 
parovarian cysts they are sometimes more laterally located than the 
ovarian tumor. Per vaginam the base feels more fleshy and occa- 
sionally both ovaries may be felt. The ovaries are, however, not 
usually within reach. 

Prognosis. 

As the tumor grows slowly it requires a much longer time to cause 
graver symptoms than the ovarian. Indeed, it generally takes a very 
long time for it to produce fatal results. We meet with them not un- 
frequently with a history of six, ten and twenty years standing. They 
occasionally rupture and entirely disappear without any apparent 
cause except distension. Indeed, while I have not seen enough of 
them to enable me to decide that point, I think the cyst is generally so 
frail that it would burst before it grew to great dimensions. 



Treatment. 

As this tumor sometimes disappears after tapping, is monocystic and 
contains bland unirritating fluid, there is much less danger from evacu- 
ating it than the ovarian cyst. Upon these considerations is based the 
practice pursued by some of relying on tapping as a remedy. There 
are, however, so few instances in which it is not followed by a reaccum- 
ulation that it is hardly worth while to make any favorable calcula- 
tions upon it in this respect. Hence the operation for the removal of 
the growth should be the prime consideration. The exceptions to this 
rule, would, as in ovarian disease, depend on unusual circumstances. 
In making up our judgment as to treatment, we should remember 
that there is much more encouragement to resort to what is generally 
considered palliative measures than in the treatment of other cystic 
tumors, and give this consideration due weight in deciding the matter. 



PAROVARIAN TUMOR — TREATMENT. 



787 



Small tumors may be entirely and safely cured by exposing the cyst 
by an incision through the abdominal walls, evacuating it, stitching it 



Fig. 305. 



**4& 




Fig. 306. 




Enucleation of Cyst of the Broad Ligament. 

in the wound, inserting a drainage tube and allow it to remain five or 
six days, in which time the cyst is obliterated. Enucleation is much 



788 OVARIOTOMY. 

more difficult in a tumor that does not extend above the iliac fossa 
than in one large enough to produce considerable distension of the 
abdomen. 

The operation for the removal of the c} 7 st differs in no respect from 
that of ovariotonw except that, as it is not generally pediculated, 
enucleation becomes necessary. Of course when there is a pedicle 
which can be ligated, the operation is identical with that of ovari- 
otomy. When, however, after opening the peritoneal cavity, we find 
the base of the tumor embraced wholly or in part by the fleshy cover- 
ing derived from the broad ligament, we cannot remove it without 
separating this enveloping tissue from the cyst. These fibrous bands, 
and the thickened peritoneal covering so closely adhering to the tumor 
are not adhesions, they are the original coverings of the growth and 
have grown with the tumor sufficiently to retain their original rela- 
tionship with the parovarian neoplasm. And fortunately they are 
connected w T ith the cyst proper by not very firm connective tissue 
which permits the two surfaces to be separated without doing violence 
to either. 

It is probably always better to evacuate the cyst by means of the 
large trocar and draw it through the external incision where it should 
be securely held by the Nelaton forceps or by the hands of an assist- 
ant. Thus brought fully in view the operator can easily see the upper 
edge of the fibrous covering. The separation should be commenced 
pretty high up on the cyst, by carefully making an incision through 
the covering around the entire cyst. The touches of the knife should 
be so delicate as to preclude the wounding of the cyst. We may tear 
the envelope with the fingers but it is not the best way to do, for one 
of the most important items in the operation is to preserve this cover- 
ing in its entire extent around the sides of the tumor to and beneath 
the bottom. After the circular incision is made, we may with the 
handle of the scalpel turn out the edge of the enveloping tissues until 
a start at enucleation is made. Then this covering should not be 
stripped down in shreds, but the finger should be carefully inserted 
between the two surfaces and carried all around the sides and down 
under the bottom of the cyst, when the latter may be easily lifted out 
of its bed. If the operator is successful thus far the peritoneum is 
clean and has been subjected to the least possible violence, and the 
cup-shaped stump from which the tumor has been enucleated is of 
such a shape as to retain all blood or serum that may flow from lacer- 
ated surfaces, and be drained through the external wound. The free 
border of this hollow stump may be brought up through the lower 
end of the w ? ound and drained by a glass or rubber tube. Of course 
during the enucleation the peritoneal cavity should be w r ell guarded 
to prevent it from becoming befouled. While it is probably generally 
better to use a drainage tube, I am sure it is not alwavs necessarv. 



PAROVARIAN TUMOR TREATMENT. 789 

When the right parovarium is the seat of the growth the vermiform 
process and the caecum are generally lifted high up on the side of the 
tumor. They are not, however, in the way of enucleation done in 
this way, and do not require separate treatment. 

In fixing the stump in the external incision it should not be drawn 
through the wound so as to cause any tension, as ample allowance 
ought to be made for the natural shrinkage in retractions. 



CHAPTER XLVIII. 



FALLOPIAN TUBES. 



The Fallopian tubes are sometimes absent ; this is the case gener- 
ally when the uterus is absent. But, according to Rokitansky, they 
are not always wanting when the uterus is. One, or even both of 
them, may be wanting when there is no other fault in the genital 
organs. Occasionally they are met with of diminutive or rudimentary 
size. They are also deformed, having two sets of fimbrillse, one at the 
end and the other nearer the uterus, with openings at both places ; or 
bifurcated, the branches entering the uterus at different points. Or 
one may be longer than usual, and enter the cervical portion of the 
uterus as mentioned and described b} x Pole, and quoted by Scanzoni. 
They are often displaced with the uterus and with the ovaries, and, 
with the latter organs, are found to enter into the formation of a 
hernia. 

Salpingitis. 

Salpingitis is by far the most important as well as most frequent 
affection of the Fallopian tubes. It is found to exist in two different 
forms, endo-salpingitis and mural salpingitis. This last is often asso- 
ciated with perisalpingitis. The inflammation of the mucous mem- 
brane or endo-salpingitis, may be regarded as catarrhal in cases in 
which the inflammation is mild and its products sero-mucous and 
non-irritating ; and gonorrheal when the secretion is muco-purulent 
and highly poisonous. I think we should hold this distinction be- 
tween common catarrhal and gonorrheal inflammation as of consider- 
able importance, especially on account of the prognosis. There is a 
great difference in the intensity and extent of the inflammation, the 
catarrhal being very much less intense and extensive than the gonor- 
rheal. In either case the inflammation extends from the endometrium. 
The catarrhal arises in the uterus more as the result of a depressed 
condition of the vital forces, while the gonorrheal comes from an active 
virus applied to the mucous membrane of the genital passages awak- 
ening an inflammation which spreads with great rapidity and inten- 
.sity, and in subsiding lingers in perpetuity. 

The catarrhal variety probably does not spread beyond the tube, 
while the gonorrheal poison lights up inflammation in the parts con- 
tiguous to the fimbria, the peritoneum and ovaries, and probably 
deeper tissues. When the tube becomes occluded in catarrhal endo- 
salpingitis the thin sero-mucous collection in the distended tube is 
called hydro-salpinx, while the collection of the contents of the tube 
in gonorrheal or septic inflammation constitutes pyo-salpinx. 



SALPINGITIS SYMPTOMS. 791 

I have seen many instances in which I believe chronic gonorrheal or 
gleety discharge in man has given rise to salpingitis in the female. 

In mural salpingitis the lumen of the tube is greatly increased 
and the walls thickened. On the external or peritoneal surface there 
generally are found fibrinous deposits, some large and some small, and 
occasionally the tube is bound to the contiguous surface with fibrinous 
bands. The vessels become distinctly visible and the color of the 
organs brighter. As seen in the patient before removal they are often 
scarlet red. The whole organ is greatly elongated but retains its tor- 
tuous character. 

Peri-salpingitis may accompany either of the above mentioned 
forms of tubal disease. The peritoneal and connective tissue around 
and near the tube may become inflamed without the process extend- 
ing to a great distance or depth, or the inflammation may involve the 
whole broad ligament, and in either case reach the ovary. Peri-salpin- 
gitis connected with gonorrheal inflammation of the tube is doubtless 
often caused by the spilling of pus from the extremity of the tube, and 
inflammation may extend to the surrounding parts as the effect of con- 
tiguity. Until recently it has been the belief of the profession that 
the Fallopian tube was seldom if ever inflamed except when involved 
as a part of general pelvic phlogosis ; and that the explanation of the 
chronicity of the process in it was that it outlasted the more extensive 
and surrounding inflammation. This is undoubtedly true in some 
cases of septic pelvic inflammation. Now the opinion seems to be 
forming, if it is not so formed, that the tubal inflammation is generally 
primary and independent ; and becomes the source of the surround- 
ing disease — as local peritonitis and cellulitis. 

Symptoms. 

It will not be necessary to dwell upon acute salpingitis, as it is gen- 
erally only a part of an extensive perimetric inflammation and cannot 
be separately recognized. There are in fact no distinctive symptoms 
of simple chronic catarrh on the tube. When however, the tube is 
closed up so that the secretion is retained, the bulk of the tumor re- 
sulting may give rise to symptoms of weight and pressure. 

In pyo-salpinx the symptoms are generally pronounced and persis- 
tent. A sense of heat and burning with cramping pains or severe 
aching and tenderness is felt in the iliac region of the side affected. 
And I think another important symptom of chronic purulent salping- 
itis is recurrent attacks of acute perimetritis, probably the effects of 
the poisonous fluid flowing from the extremity of the tube upon neigh- 
boring tissues. The pains attending the tubal inflammation are 
usually aggravated by the approach of the menstrual ppriod. And 
Mr. Lawson Tait believes that the menstrual flow may be increased 
as one of the symptoms. In fact the generative functions are deranged 



792 FALLOPIAN TUBES. 

in many ways. The general symptoms are those of nervous prostra- 
tion, hysteria, neuralgia, despondency and even deep melancholia. 
Although not always, there often are anaemia and emaciation. 

Diagnosis. 

A correct diagnosis by ordinary methods is sometimes impossible ; 
occasionally, however, it is not difficult. When the tube is only mod- 
erately enlarged and not indurated it is very difficult to distinguish, 
but often by examining the patient under the influence of anaesthetics 
through both the vagina and rectum, we may trace the tube down the 
posterior border of the broad ligament into the cul de sac behind the 
'uterus as a soft cord resembling a small intestinal convolution, some- 
times when the abdominal walls are thin by bimanual examination 
we may trace its course along the surface of the broad ligament. To do 
this the finger of one hand in the vagina should be passed up to the 
brim of the pelvis and swept slowly around as near the brim as possible 
from before backward while the hand above presses the abdominal 
wall as near as possible to the finger tips as they move towards the 
sacrum. In this way the fingers in the pelvis may often feel the soft 
serpentine tube for some distance along the side. The efforts to ap- 
proximate the opposing fingers should be made with gentleness and 
the force applied slowly, giving the fingers time to appreciate by the 
touch the organs they pass over. If the tube is filled to any extent 
by pus, blood or serum so as to make a tumor, by this method of ex- 
amination they will be pretty certainly detected. Should such accu- 
mulation be discovered the manipulation of them should be very 
guarded as too much rudeness may rupture the sac and flood the ab- 
dominal cavity with pus and induce severe, if not fatal peritonitis. 

In addition to the indistinctness of a small and soft tube there are 
three other important conditions not infrequently present that render 
our efforts at diagnosis unavailing. They are a thick layer of adipose 
matter in the wall of the abdomen, a hardness and unyielding state 
of the abdominal muscles, and the adhesions and indurations result- 
ing from previous inflammatory attacks. If the degree of one or all 
of these conditions is very considerable it is an absolute bar to a 
definite diagnosis. Then the question as to the propriety of an ex- 
ploratory incision comes up for decision. This question will occur 
only in cases of great gravity and obstinacy. If every rational measure 
for the relief of the patient has been tried and failed, while she is 
suffering greatly from what would appear from the symptoms a disease 
either of the tube or ovary, I believe the risk of an exploration is 
justifiable and that the operation is demanded. In many cases it is 
the only way to arrive at a correct diagnosis, and the incision may, 
by extending it, serve as the opening through which extirpation may 
be effected. 



SALPINGITIS — TREATMENT. 793 

Prognosis. 

There is probably not yet sufficient accuracy in the diagnosis of 
salpingitis to enable us to separate it from inflammation of neighbor- 
ing organs and tissues, or to distinguish cases in which it is simple or 
complicated, or even between the different varieties of tubal inflamma- 
tion. The prognosis would vary with these conditions and be influenced 
by their uncertainties. But I think a reasonable prognosis may be 
founded upon general principles, by considering the causes, the length 
of time the case has withstood judicious treatment, the constitutional 
or diathetic state of the patient, her ability and disposition to co-operate 
with us intelligently and faithfully in our efforts for her relief, and 
her possession of the means to command every facility for appropriate 
treatment. 

When complicated with ovaritis or suppurative cellulitis the prog- 
nosis would, of course, be greatly modified by that circumstance. In 
the simple catarrhal and mural varieties the prognosis would be very 
much more favorable than the gonorrheal form. Recent cases would 
be more favorable than those of long standing. Those in patients of 
tuberculous diathesis or anaemic habit, in the poor, or ignorant who 
are surrounded by adverse circumstances or who cannot be made to 
appreciate the importance of following out the treatment, would 
necessarily be unfavorable. 

Most of all we should apply the prognostic test, of a well studied 
course of treatment perseveringly carried out for a sufficient time to 
be assured that it will not succeed. Schrceder says in the twenty- 
ninth volume, second part, of Archives fur Gynecologie, that there are 
cases in which the contents of a pyosalpinx becomes thick and re- 
mains in the tube and is harmless. 

Treatment. 

The almost complete monopoly affected by surgeons in the treat- 
ment of chronic salpingitis is not an unqualified blessing. Indeed it 
is quite certain that the loss of the tubes and ovaries by surgical 
methods is in many instances a needless sacrifice. Patient, careful 
and protracted treatment will often cure them and compensate the 
woman for the trouble and time required by saving those valuable 
organs. There is usually insufficient attention given to general treat- 
ment in the management of cases of chronic inflammation of the 
tubes. It is necessary to promote the vigor of the nervous and vas- 
cular systems by improved nutrition, to regulate the distribution of 
the blood, to excite and maintain at their normal degree of activity 
the secretory and excretory functions by exercise and food that have 
this effect; and as the process of repair is slow, plenty of time is 
necessary to the successful treatment. 



794 FALLOPIAN TUBES. 

. It will be readily understood by the reader that the treatment 
adapted to salpingitis is the same as that required for inflammation of 
the ovary, local peritonitis and cellulitis. After the acute stage of any 
of these affections has passed off and left the patient so prostrated as 
to oblige her to keep her bed, the difficulties of the case will be in- 
creased to a great degree, and every effort must be made to restore her 
physical energies and correct the habits of invalidism to which she is 
reduced. While in some cases this will be impracticable, in many it 
may be accomplished ; but in all we will meet with many difficulties. 
The patient has perhaps contracted the habit of resorting to stimulants 
for support, to anodynes for rest or comfort, to laxatives to overcome 
constipation, and to the idea that she " cannot " do otherwise. 

One of the first things to do is to induce the patient to agree to dis- 
cipline, and accept measures that will result in a change of all the 
habits impeding her progress toward recovery. An understanding of 
this kind will, in the majority of cases, facilitate the management of 
them very greatly. But it will require constant vigilance and much 
prompting to aid the patient in maintaining her resolution. Patients 
who are laboring under great nervous prostration, an almost neces- 
sary concomitant of weak will or feeble resolution, cannot be man- 
aged on a better plan than that suggested by Dr. Weir Mitchell, 
and now familiar to the profession. The main items of it are isola- 
tion, absolute rest, simple diet, passive exercise by the use of massage 
and electricity, succeeded in a gradual way by active exercise, full 
diet, and exposure to the open air. Of course this treatment will re- 
quire an intelligent, faithful, and vigilant nurse. 

In the more acute cases massage and good feeding are to be regu- 
lated according to conditions, always keeping in mind the necessity of 
as high a state of nutrition as practicable. Medicines are not to be 
relied upon as the only means to effect a cure of chronic salpingitis. 
Before all considerations we should avoid opium, and in fact all ano- 
dynes as much as possible, and never continue them after urgent exi- 
gency has passed away. The habitual use of laxative medicines is 
not as disastrous as that of anodynes, but is sure in most cases to affect 
the process of digestion badly. A health y laxity of the bowels may 
be maintained by ventral massage and the systematic use of fruits, 
vegetables, and bread made of unbolted flour. A special study of 
each case with reference to the adaptation of laxative ingesta will 
usually enable us to find effective articles for the purpose. The 
reader will find the subject of constipation treated in a more extended 
form in the general treatment of uterine disease in this book. 

Pain may be frequently relieved by the use of sinapisms, cataplasms, 
friction, liniments, etc. Both physician and patient should regard an 
anodyne as an indulgence, to be avoided when possible. Of course 
there will be times when anodynes and laxatives will be allowable, 



SURGICAL TREATMENT. 795 

but they should both be regarded as temporary measures. We find 
indications for rest and the free use of anodynes in the earlier stages 
of gonorrheal or septic cases. 

Some of the local means for controlling general pelvic inflammation 
will expedite the cure ; such as large hot-water vaginal douches, gly- 
cerine-cotton tampons, sitz baths, hot poultices, etc. 

Surgical Treatment. 

After the failure of a well-conducted medical treatment, we are 
forced to resort to surgical means for the relief of the otherwise in- 
curable patient. The surgical procedures suggested are dilatation of 
the tubes by an appropriate probe or catheter, aspiration for serous, 
sanguineous and purulent accumulation, and extirpation. 

Dilatation of the tube by a sound introduced through the uterus is 
said to have been accomplished. In two instances, not cases of salpin- 
gitis, I have passed the common uterine sound through the tubes 
several inches into the abdominal cavity. But this kind of catheteri- 
zation or probing cannot be regarded as a generally practicable remedy, 
at least in the present state of our knowledge and skill. When, how- 
ever, we look back a few years at what has been done in gynecological 
surgery, we may well be encouraged to believe that this may become 
one of the recognized means of evacuating Fallopian accumulations. 

Aspiration may be regarded as practicable in some cases. The sub- 
ject of aspiration, however, stands more in the position of a suggestion 
for the treatment of exceptional cases than as a recognized and com- 
mendable remedy to be resorted to generally. Judging from the 
benefits resulting from aspiration to evacuate accumulations else- 
where, it is reasonable to expect that it may to some extent supersede 
the more dangerous operation of extirpation. This operation may be 
done through the vagina, rectum, or abdominal walls. Whenever it 
can be reached — and this can be not unfrequently done — through the 
vagina, this should be the selected way. Aspiration through the ab- 
dominal walls is dangerous because of the likelihood of pus getting 
into the peritoneal cavity. 

But as the question of surgical treatment now stands, salpingotomy 
is regarded as the operation very generally to be preferred, and appli- 
cable to most cases. I need only refer the student to oophorectomy 
for a description of the mode of operating to remove the tubes. In 
fact, I would expect always to remove both ovary and tube at the 
same operation. 

Theoretically one would see the dangers of extra-uterine pregnancy 
in leaving the ovary after the tube was taken out. When the opera- 
tion is to remove a tube distended to any considerable extent with 
pus, blood, or serum, the operator should be careful to place two 



796 FALLOPIAN TUBES. 

double ligatures around the pedicle a short distance from each other 
and cut between them. This is to avoid the escape of the pus or other 
contents into the abdomen ; and for the same reason great care should 
be taken in manipulating the tumor. The sac is often so thin and 
frail it ruptures by slight pressure. Should pus gain access to the 
peritoneal cavity great pains must be taken to cleanse that cavity. 
Warm water from a pitcher should be poured through the wound 
until the pus is thoroughly washed out. The water can be carefully 
sponged out until all is removed. The process of removing the water 
may be facilitated by turning the . patient on the side. When it is 
remembered that this tube is sometimes distended to the size of a 
goose-egg, these precautions will appear valuable. 

Hematosalpinx, etc. 

A collection of blood of considerable size is sometimes met with in 
the Fallopian tubes. Sometimes it is so great as to give much incon- 
venience from pressure upon the surrounding parts and a sense of 
distension. Such collections may constitute a .part of hematometra 
from retained menses. In this connection the blood is probably forced 
into the tubes by the resistance of the distending uterus, and will gen- 
erally be evacuated when that organ is emptied. In other forms of 
hemato-salpinx both ends of the tubes are closed. The most plausible 
explanation of the accumulation is that the blood escapes from the 
lining membrane of the tubes something in the same w r ay that it is 
extravasated through the mucous membranes of the uterus. The 
blood of hemato-salpinx is sometimes coagulated, more frequently it 
is thin, flowing easily when the cavity is opened. One would suppose 
that in this liquefied form it was absorbable and susceptible of spon- 
taneous disappearance. 

The diagnosis and treatment are the same as those of hydro-sal- 
pinx. 

The tubes are doubtless the channel through which inflammation of 
the uterus finds its way into the peritoneal cavity, and also the con- 
duit for fluids — pus, blood, mucus, etc. — from the uterus to the peri- 
toneal cavity. As they are not seldom found dilated so as to admit a 
uterine sound to pass them, — Hilclebrant, Matthew Duncan, Thomas 
Budd, and others, have seen and diagnosticated dilatation of the 
Fallopian tube during life, — we need not be surprised at the transi- 
tion of fluids through them in both directions. Thus the serous con- 
tents of the peritoneal cavity may be passed into the uterus and 
vagina. The reader will not fail to see the importance of diseases of the 
tubes, on account of the sterility that would result from obliteration 
or constriction of them, or the clanger from a too free communication 
between the peritoneal sac and the uterine cavity. 



etc. 797 

Cancer and tubercles of the Fallopian tubes are not often observed in- 
dependent of the existence of the same disease in the surrounding- 
tissue. They are generally though not necessarily involved in cancer- 
ous degeneration of the ovary and the uterus. 

Hypertrophy and Atrophy of them accompany the same changes in 
the uterus. They are enlarged when the uterus is by tumor, inflam- 
mation, congestion, or pregnancy, and become atrophied as the uterus 
diminishes in size, in old age or from any other cause. Dropsy of the 
tubes is occasionally observed. 

We also meet with small serous cysts attached to the fimbriated ex- 
tremity of the Fallopian tube. They are usually small cysts, distended 
by serum, scarcely ever exceeding the size of the finger's end. 



CHAPTER XLIX. 

COCCYGODYNIA, COCCYALGIA. 

Neuralgia of the Coccyx. 

These terms are used to denominate one of the several peculiar 
neuroses of the pelvic organs, especially those situated at the bottom 
of the excavation. It belongs, I think, clearly to the same class of 
cases as vaginismus, urethrismus, spasm of the bladder, rectum, etc., 
and is purely a nervous affection. 

They are all peculiar hyperesthesias, and sometimes have a demon- 
strable basis of excito-motor origin, as fissures, ulcers, inflammation, 
etc., while in other instances there seems to be no material change in 
any of the organs. 

That coccygodynia, like vaginismus, is often associated with uterine 
disease, disease of the rectum, bladder, urethra, etc., is certain from 
observation. Whether these more common affections, after continu- 
ing a long time, may excite the nerves into a state of instability that 
becomes permanent or not, is a question worth asking in this connec- 
tion. In common with other nervous affections having a reflex ori- 
gin, may not the symptoms become a disease, and remain an indepen- 
dent affection after the excito-reflex cause has been removed ? The 
irritation so protracted and unremitting I think may and often does 
inauce organic change in the nerves or the subordinate centres with 
which they are connected, and thus perpetuate the symptoms. 



Structure Affected. 

There was, in all cases I have examined, room to doubt the exact 
tissue affected, whether in the periosteum, interosseous ligaments, 
muscles, or nerves. 

Symptoms. 

Pain on moving the coccygeal bone, in sitting down, rising up, 
passing the faeces, coughing, sneezing, walking, or standing. In bad 
cases the patients are not able to sit, stand, or walk without great dis- 
comfort, and are so pained by the sitting or erect posture that they 
are confined to recumbency. 

They thus lose their general health and become permanent invalids. 
This is very rare, however, and the most of the cases we meet with 
are in patients who enjoy a tolerable state of general health, but are 
continually annoyed by everything that causes contractions of the 



DI A GNOSIS — PROGNOSIS — TREATMENT. 799 

muscles attached to the coccyx or closely connected with them. They 
sit on one side of the buttocks or on cushions that remove the pres- 
sure from the coccyx. They rise to the standing position with great 
care, and must be very guarded in walking, coughing, or sneezing, etc. 

Diagnosis. 

This is made by considering the history of the case and by physical 
examinations. The finger passed into the vagina or rectum, and 
pressed backward upon the coccyx, so as to move it, gives the patient 
great pain. Pressure exerted upon the posterior surface, with suf- 
ficient force to move it, causes even greater pain. When the disease 
is severe the suffering is so great that it is with difficulty we can ex- 
amine the coccyx as to its mobility. 

Dr. Jenks says that when a patient is examined under the influence 
of ether the muscles connected with the coccyx are relaxed, while 
they are very strongly contracted when the patient is not etherized. 



There seems to be very little tendency to spontaneous subsidence 
of coccygodynia. 

The menopause does not affect it as it does most of the pelvic dis- 
eases, and it is often a long time after the change of life before the 
patient recovers. It occurs in the young nulliparous and parous 
women alike, but not in the senile. It generally causes more suffer- 
ing in women who are bearing children. 

Treatment. 

The palliation of the symptoms in coccygodynia consists in the 
use of anodynes and tonics, the former to relieve the great suffering 
for the time. They may be used in suppositories per rectum, per 
vaginam, or hypodermically. We can add greatly to the comfort of 
the patients also by contriving cushions or easy chairs for them. 

A tonic or roborant course of treatment will sometimes brace up 
her nervous system so that the patient can bear her ills without 
breaking down physically. Among the means to accomplish this 
end, when the patient is not too bad, travel is of great service, a 
change of climate from hot to cold in the summer, and from cold to 
warm in the winter. Quinine and iron administered internally, 
with liberal and systematic feeding, contribute to the same purpose. 

In the earlier periods of coccygodynia we may hope to arrive at a 
cure by searching for and removing all disorders in the neighborhood, 
founding our treatment upon the idea of removing the excito-reflex 
centre of disturbance. 

Dr. Robert Barnes, of London, believes that it is caused by retro- 



800 COCCYGODYNIA — COCCYALGIA. 

versions of the "uterus. Anal fissures, hemorrhoids, ulcers in the 
rectum, should command our special attention if they exist, and 
every pains should be taken to restore all deviations from general 
health. 

After the disease has existed long enough to become an indepen- 
dent affection, probably nothing short of a surgical operation will 
result in a cure. 

To the late Dr. Nott belongs the credit of first describing this dis- 
ease and devising a surgical operation for its cure. He called it 
neuralgia of the coccyx, and, after trying all other measures that 
occurred to him, extirpated the bone. His operation consisted in 
cutting through the attachments of the bone on each side, from the 
base to the apex, everting it and dislocating it from the sacrum. 

This may best be done by incising the integument in the central 
line, and raising and turning aside the flaps until both margins of 
the bone are exposed. The next step is to cut carefully down 
through attachments at the point of the coccyx and introduce a 
blunt-pointed bistoury, or the point of scissors, and separate the 
attachments upward to the base on both sides. The bone can then 
be lifted up and turned backward to expose the articulation, which 
may be divided by a bone forceps or a strong knife. The loose cel- 
lular tissue, on the inner surface of the bone, easily gives way as it is 
lifted from its bed, or may be divided by the knife. 

There is generally very little hemorrhage, and the bleeding will 
in a few minutes subside. All that remains to be done is to close 
the wound by replacing the flaps and joining them by four or five 
stitches. 

This is neither a dangerous nor a difficult operation, and is very 
effective in a curative point of view. 

In 1858 Professor James Y. Simpson, apparently with knowledge 
of Dr. Nott's description of the operation for this affection, published 
in the London Medical Gazette his Lectures on the Diseases of Women, 
in which the disease is recognized and his operation described. His 
operation consists in the subcutaneous division of the connections of 
the bone without removing it. 



INDEX OF AUTHORS. 



Abernethy, 404 

Adams, J. A., 528 

Alexander, W., 511, 527, 528, 530, 534 

Allen, E. P., 642, 646 

Allen, J. M., 444 

Alquie, 528 

Amussat, 535 

Andrals, 271 

Anthonv, 777 

Apostoli, 655, 656 

Atlee, W. L., 619, 626, 663, 703, 721, 722, 

733, 747 
Atthil, Lombe, 306, 629, 642, 643 
Aveling, 277 

Baker, William H., 599, 600, 656 

Barbour, 42, 211 

Bardenhauer, 535 

Barker, Fordvce, 193 

Barnes, Robert, 135, 752, 799 

Battey, Robert, 428, 673, 6S1, 687, 746 

Baudelocque, 550 

Baum, 606 

Beale, L. S., 722, 723 

Beard, 352 

Beanchardat, Madam, 550 

Becquerel, 394, 577 

Beers, 548 

Bengelsdorf, 628, 642 

Bennett, J. H., 61, 355, 371, 387, 625, 719, 

721, 722 
Bernutz, G., 331,461 
Billroth, 215, 606 
Bird, Fred., 715 
Bischoff, 207, 214, 510 
Bixbv, G. H., 340, 342 
Bliss, J. C, 160 
Blum bach, 703 
Bogue, 697 
Boismont, 279 

Bozeman, 255, 270, 2"1, 272, 274, 278 
Brainard, 238 
Braun, C, 114, 242 
Breisky, 507 
Brown, 654, 656 
Brown, J. B., 241, 242, 243, 662, 714, 721, 

728, 733, 739, 743, 748 
Brvant, 137 

E., 631, 642 



Buckingham, C. 
Bucklev, 234 
Budd, il6, 796 
Budge, 277 
Budin, 102 



Burnham, 673 

Butlin, 608 

Buttles, 424, 434, 439 

Bvford, 513, 519, 535, 642. 74' 

Byrne, John, 504, 594, 598 



■47 



Campbell, H. X, 515, 776 

Carlet, 655 

Cazeaux, 386 

Chadwick, 49, 303, 621 

Chamberlin, 328 

Chambers, 328 

Chantreuil, 32 

Charpentier, 169, 193, 194 

Chiari, 746 

Chrobak, 629, 642, 643 

Clay, J., 580, 585, 673 

Cornil, 593 

Coste, 312 

Costilhes, 386 

Courtv, 519 

Cowan, George, 631, 642, 643 

Crandall, J. P., 638 

Croft, 235 

Crosse, 546 

Cutter, 449, 507, 508, 522, 644, 656 

Czerny, 535, 603 

Danvou, 386 

Davis, R., 746 

Dean, H. W, 631, 642 

Dewees, 153, 154, 312, 370 

Dieffenbach, 509 

Dieulafoy, "36 

Donaldson, S. J., 524 

Drvsdale, T. M., 720, 723, 726 

Dudley, E. C, 440 

Dumas, 188 

Dumont-Pallier, 506 

Duncan, John, 206, 211, 449, 522, 536 

Duncan, J. Matthews, 171, 206, 211, 448, 

796 _ 
Dunglison, 385 

Emmet, T. A , 124. 205, 211, 214, 231, 
240, 254, 255, 257, 258, 262, 263, 320, 
383, 435, 437, 439, 440, 449, 666, 667 

Engert, 116 

Engelman, 114, 277, 444, 516 

Erich, 124 

Esmarck, 672 

Etheridge, J. H., 630, 631, 642 
I Eustache, 772 
51 



802 



ItfDEX OF AUTHORS. 



Fisher, 631,642 

Fitch, T. D., 114, 307, 470, 519, 523 

Fitz, 340 

Foster, 42 

Fowler, 500. 523 

Fox, W., 640 

Freund, William A., 21, 25, 28, 202, 207, 

208, 210, 211, 214, 601, 603, 605 
Fricke, 509 
Fritsch, 509, 510, 523, 604 

Garrignez, 27 

Gehrung, 512, 522 

Gerardin, 509 

Gillette, 124, 483 

Gilraore. J. F., 746 

Gluge, 721, 722, 723 

Goodell, 304, 336, 436, 448, 449, 690, 746, 

747 
Goodman, 135, 231 
Goodrich, G. C, 327, 328, 635, 642, 645, 

646 
Gosselin, 386 
Goupil, 460, 461 
Grav, 52 

Green, S. W., 699 
Greenhalgh, 422 
Gunn, Moses, 631 

Hackenberg, 506 

Hacker, 671 

Hall, Marshall, 482 

Hanks, 132, 306, 440, 475, 478, 522, 536 

Hart, D. B., 23, 30, 42, 211 

Hatch, 550 

Hay, Thomas, 557 

Hegar, 210, 449, 510, 670, 681 

Henle, 26. 29, 31 

Hennig, 535 

Herrick, 536 

Hewitt, 240, 512, 522 

Higbv, 120 

Hildebrandt, 628, 642, 646, 796 

Hillas, Thomas, 757, 759 

Hodder, E. W., 632, 642 

Hodge, 234, 366, 412, 500, 507, 521, 523, 

531, 536 
Holmes, 235 

Howard, H. C., 630, 642, 646 
Hnguier, 146 

Hunter, 124, 313, 314, 327, 536 
Hyrtl, 52 

Jackson, A. E., 135, 328, 537, 630, 642, 

643 
Jenks. E. W., 114, 630, 642, 799 
Jewell, J. S., 49, 352 
Jobert, 274 
Jukes, 633, 642 

Keating, 643 
Keith, 670 
Keith-Skene, 535 
Kelly, H. A., 535 
Kemper, 160 



Kimball, 654, 656, 673 

Kinlock, 524 

Kiwisch, 733, 744, 745 

Kob, 758 

Koeberle, 535, 599, 600, 673 

Kuestner, 207, 211 

Kuster, 504 

Labbe, Leon, 671 
Lahs, 759 

Lane, L. C, 601, 603 
Langenbeck, 214, 216 
Lazarevitsch, 509, 522 
Lebert, 702 
Lee, 733 
Lefort, 504, 511 
Leopold, 603 
Lewer, 137 
Lister, 770 
Loewentbal, 536 
Low, J. H., 700 
Luecke, 215 
Lushka, 22, 50 
Lusk, 736 

Mack, 340 

Mackintosh, 326 

Malgaigne, 509 

Martin, A., 202, 208, 217, 504, 510, 606 

Martin, F. H., 655, 656 

Mason, E., 758 

Mayer, 506 

McClintock. 149, 544, 557 

McDowell, 750 

McLeod, G. H. B., 749 

Meigs, 142, 547, 548, 550 

Merriman, H. P., 631, 636, 642 

Meude, 509 

Meyerbeer, 606 

Miller, 117, 572 

Miller, De Laskie, 631 

Mitchell, S. W., 352, 688, 694, 794 

Molesworth, 122 

Montgomery, 312 

Morris, 63i; 642, 646 

Mueller, P., 505. 535, 603 

Munde, 124, 434, 436, 644, 673, 745, 746, 

757, 758 
Murry, 243 

Nelaton, 444, 602 

Nelson, 120, 339 

Neugebauer, L. A., 504, 511 

Nicholson, 757 

Noeggerath, 114, 116, 390, 391, 445, 745 

Nott, 120,124,800 

Nunn, 697 

Oldham, 312 
Olshausen, 535, 603 
Owen, 757 

Pajet, 702, 721 
Pallen, 124,436 
Panas, 504 



INDEX OF AUTHORS. 



803 



Papin, J. L., 230 

Paquelin, 749 

Parkes, C. T., 671 

Parvin, 294 

Paulv, 707 

Pawlick, 137 

Pean, 601, 604, 670, 673 

Peaslee, E. R., 306, 320, 385, 440, 500, 

506, 536, 703, 744, 748, 777, 779 
Pole, 789 
Polk, 517, 535 
Priestly, 509, 522 
Proctor, 736 
Puesch, 239 

Ranvier, 593 
Reamy, 509, 510, 545 
Redner, 605 
Ricord, 234 
Rockwell, A. D., 294 
Rokitansky, 703 
Roser, 507 
Russel, 633, 642 
Rutenberg, 135 
Rutgen, 188 

Savage, 28, 31, 41. 101, 102 

Sawver, E. W., 666 

Scanzoni, 148, 239, 312, 352, 507,744,745, 
789 

Schatz, 162, 166 

Schroeder, C, 42, 504, 522, 524, 605, 606, 
670, 671, 673 

Schultze, B. S., 26, 63, 86, 500, 507, 516, 
522 523 

Scott, 449, 450, 508, 509, 522 

Semeleder, 746 

Simon, 136, 264, 270, 327, 449, 475,509, 
510, 512,589 

Simpson, Alex. R., 211 

Simpson, Sir James Y., 114, 154, "155, 289, 
295, 322, 326, 467, 571, 586, 587, 662, 
710, 718, 728, 732, 735, 740, 742, 743, 
800 

Sims, J. Marion, 56, 57, 58, 114, 120, 123, 
124, 133, 135, 154, 231, 233, 240, 241, 
242, 243, 251, 253, 258, 263, 265, 276, 
303, 318, 322, 326, 387, 425, 430, 446, 
449, 475, 482, 501, 503, 504, 513, 536, 
550, 664, 665, 727, 756 

Sims, H. Marion, 505, 523 

Skene, 135 

Smith, Albert, 513, 514, 519, 523, 537 

Smith, Heywood, 535 



Smith, Tyler, 382, 550, 552, 556 

Southam, 733 

Spiegelberg, 396 

Squibb, 644, 645, 652 

Stoltz, 482 

Storer, H. R., 146, 234, 235, 673 

Strange, 633 

Stratz, 577 

Stndlev, 124, 523 

Sutton^ R. S., 668 

Tait, 196, 207, 211, 212, 215, 216, 477, 535, 
681, 690, 691, 693, 791 

Tarnier, 32 

Tavlor, J. E., 430 

Thomas, T. G., 30, 114, 116, 124, 304, 308, 
328, 500, 505, 507, 512, 513, 522, 524, 
538, 656, 666, 667, 673, 746, 796 

Thompson, J. H., 633, 642 

Thornton, 782 

Tilt, 343 

Trenholme, 674, 675 

Trommhold, 7 16 

Veit, 253 

Virchow, 25, 331, 702 

Warn, William H., 637 

Warner, L. F., 398, 633, 642 

Wells, Spencer, 670, 673, 703, 704. 727, 

736, 752, 754, 756, 773, 777, 779, 782 
Wernich, 644 
Werth, 504 

West, 158, 544, 546, 572, 712, 733, 744 
Wev, W. C, 632, 642, 644 
White, Dr. Carrie N., 531 
White, J. L., 554 
White, J. P., 434, 547, 548, 550, 552, 554, 

556, 629, 642, 643, 645 
Whitecomb, 757 
Whitehead, 380 
Wickersham, 560 
Williams, John, 277 
Williams, J. F., 622 
Wilson, H. P. C, 598 
Winckel, 97, 135, 137, 146, 328, 510, 604 
Wing. Clifton, 668, 746 
Woelfler, 671 
Wright, M. B., 309 

Yarnell, 230 

Zwanck, 481, 507 
Zweifel, 202, 220 



GENERAL INDEX. 



Abdomen, gaseous distension of, in uterine 

disease, 854 
Abdominal ovariotomy, 748 

pressure, 35, 38, 70, 81, 82, 170, 173, 
211, 487, 488 

section for uterine displacements, 505, 
535 
Abortion, 339, 370, 379, 391, 487 

as a cause of subinvolution, 568 

of uterine displacements, 498 
Abscess, aspirator in, 478 

curetting, 475, 476 

diagnosis of, 727 

discharging into bladder, 452 
into rectum, 452, 453 
into vagina, 452, 453 

due to cellulitis, 452 

to hematocele, 333, 334 

indolent, 473, 478 

laparotomy for, 476, 477 

operation through rectum, 475, 478 

pelvic, 342, 469, 478, 486 

treatment of, 473 

with pregnancy, 452 
Abscesses of the labia, 144, 146 
Absorption, summary of cases of fibrous 

tumors cured by, 641 
Accident in injection, 419 
Accidents that may occur during ovari- 
otomy, 771 
Acid, acetic, 731 

boracie, 500, 507 

carbolic, 154, 193, 196, 198, 221, 342, 
426, 428, 531, 599, 751, 761, 762 

hvdrocvanic, 154, 586 

nitric, 156, 159, 276, 426, 731 

nitro-muriatic, 397, 731 

phosphoric, 225, 731 

sulphuric, 731, 408, 506 

tannic, see Tannin. 

vegetable, 226 
Actual cautery. See Thermo-cautery. 
Acute perimetritis, 451 
Adhesions of broad ligaments, 528 

breaking up of, 516 

Fallopian tubes, 528 

in retroversion, 515 

laparotomy for, 517 

omental, 766 

of the labia, 141 

of ovarian tumors, 764, 766 
Adhesions of uterus, 395, 472, 515, 517, 617 

visceral, 766 



Adjuster, wire, 261 
Alcohol, 306, 474, 778, 783 
Alexander-Adams operation. See Alex- 
ander's operation. 
Alexander's operation for prolapse, 511 
after laparotomy, 517 
for retroversion, 527 
drainage, 531 
application, 533 
for retroflexion, 536 
Aloes, 290, 293 
Alum, 245, 247, 251, 625 
Amenorrhoea, 282, 377, 399 

electricity in, 294 

diagnosis of, 286, 287 

from anaemia, 292 

from defective nervous energy, 294 

from hvperinvolution, 570 

from retention, 286, 728, 478 

in inflammation of uterus, 424, 429 

ovarian, 690 

pathology and morbid anatomy of, 
283 

prognosis of, 289 

symptoms of, 283 

treatment, 290 
Ammonia, aromatic spirit of, 548 
Ammonium carbonate, 776 

chloride, 305, 626 
Anaemia in amenorrhoea, 292 

in cancer, 575 

in uterine displacement, 499 

treatment of, 403 
Anaesthesia, 68, 94, 135, 256, 327, 550, 551, 
762, 776, 783 

examination of the uterus during, 65 

a sympathetic symptom of uterine 
disease, 361 
Anatomy of ovarian tumors, 695 
Anatomy and physiology of the female 

pelvic organs, 17 
Anteflexion, 496 
Anteversion, 495 

pessaries, 512 

treatment of, 512 
Antimony, 244 
Antipyrin, 783 
Antisepsis, 783 
Apostoli's method, 655 
Arcus tendineus. See White line. 
Arsenic, 310, 402 
Arteries of the pelvis, palpation of, 104 

vaginal palpation of, 105 



806 



GENEKAE INDEX. 



Ascites, 725, 750, 764 
Asclepias, 309 

Aspiration of Fallopian tube, 795 
Aspirator, 478, 619, 719, 721, 795 
Atlee, 619, 663, 703, 720, 733 
Atresia vaginae, 237 
Atrophy of the Fallopian tubes, 797 
of the mammary glands, 343 
of the ovaries, congenital, 682 
of the uterus, acquired, 288 

as a result of inflammation, 

394 
congenital, 287, 343 
Atropia, 776 

Bag of waters, 162 

Baths, 415 

Battey's operation, 673, 678 

phvsical and psychical results of, 
680 
Bearing-down pain, 371 
Becquerel's summary diagnostic between 
cancer and chronic inflammation of the 
cervix, 394 
Beef-gall, 411, 412, 732 
Billroth and Leucke, 215 
Bimanual palpation of the uterus, 65 
Bischoff's operation, 207, 214 
Bismuth, 402 

Bladder, 20, 23, 50, 64, 68, 87, 118, 135, 
140, 142, 173, 223,- 235, 251, 275, 
330,361, 537,616, 732 

abscess opening into, 452, 467 

chronic inflammation of, 227 

danger of wounding, 449, 772 

diseases of, 223 

displacements of, 479 

distension of, 223, 540, 728 

foreign bodies in, 234 

hemorrhage from, 225 

hyperesthesia of, 2i5 

in diagnosis, 727, 735 

inflammation, 330, 422 

inversion of, 235 

irritable, 225, 481, 494 

palpation of the interior of, 96 

paralysis of, 223 

pressure upon, 714 

relation of the ureters and uterus to, 
50 

relation to uterus, 31, 486 

separation in hysterectomy, 602, 603 

stone in the, 231 

tenesmus, 296, 305, 540 

treatment of paralysis of, 224 
Bloodvessels of pelvic organs, 25, 51, 70, 

77, 80, 104, 143, 217, 298 
Bougies, 251 

Bowels, sympathetic disease of, 354 
Bozeman's method for vesico-vaginal fis- 
tula, 271 

apparatus, 271 
Broad hook, By ford's, 530 
Broad ligaments, palpation of, 81 
tumors of", 784 



Bromide of potassium, 403, 626 
Buchu, 226, 229 

Bulb retroflexion pessary, Thomas's, 537 
Bulbo-cavernosus. See Constrictor cunni. 
Butlin, histologic distinction between 

sarcoma and carcinoma, 608 
Buttles' lancet-shaped knife, 439 

uterine scarificator and leech, 427 
Byford's broad hook, 530 

dressing-forceps, 123 

finger-curette, 134 

operating table, 57 

probe-pointed scissors, 529 

retroversion and prolapse pessary, 
519 

uterine scissors, 441 
Byrnes's cautery battery, 595 

cautery eeraseur, 595 

cautery electrodes, 596 

Caesarian section, 753, 759 

Calcium salts, 626 

Calculus, vesical, 231 

Calomel. See Mercury. 

Cancer of the Fallopian tubes, 797 

of the labia, 149 

of the uterus, 394, 572, 606 

curetting for, 585, 589 

discharges from, 574 

hemorrhage, 574, 578, 587 

epithelial, 591 

structures, 593 

thermo-cautery in, 585 
Cancerous cachexia, 575 
Cancroid of the uterus, 590 
Cannabis indica, 585 
Cantharides, 157, 290 
Caput succedaneum, 45, 162 
Carbonic acid gas, 586 
Caruncles of the urethra, 157 
Catheter, 134, 135, 142, 198, 229, 239, 250, 
258, 261, 287, 338, 727, 480, 541, 
545, 618, 764 

Goodman-Skene's, 135 

Simon's urethral, 136 

Sims's sigmoid self-retaining, 135 

Skene's double perforated, 229 
Catheterization of the Fallopian tubes, 796 

of the ureters, 136 

of the urethra, 134 
Cauterization of the vagina and cervix, 

504 
Cautery battery (Byrne's), 595 

ecraseur, 595 

electrodes, 596 
Cavum ischio-rectale. See Ischio-rectal 

vault. 
Cellulitis. See Pelvic cellulitis. 
Central ruptures of perineum, 169 
Cephalalgia (sympathetic), 358 
Cervical and uterine cavities, length of, 

117 
Cervicitis, 388 

Cervix uteri, amputation of, 448, 454, 597, 
600 



GENERAL INDEX. 



807 



Cervix uteri, cancerous ulceration of, 573 

characteristics of, 59 

hypertrophy of, 446 

inflammation of, 387, 388, 392, 419, 
421, 437 

laceration of, 61, 435 

location of, 61, 62, 495 

of child-bearing woman, 59 

of virgin, 59 

pregnant, 61, 335 

scarification of, 424 

senile, 60 

stenosis of, 431 

ulceration of, 385, 394, 395, 481 
Chair, "Wilson's operating, 56 
Chambers's bifurcated stem-pessary, 328 
Chamomile, 730 
Champagne, 776 

Change of life, 343. See Menopause. 
Chassaignac's eoraseur, 660 
Chian turpentine in cancer of the uterus, 

580, 58o, 589 
Chloral hvdrate, 310, 403, 423, 647 
Chlorine, '587,731 
Chloroform, 154, 310, 586, 731, 758 
Choking sensation in uterine disease, 364 
Chronic inflammation of the bladder, 227 

perimetritis, 469 

retrouterine hematocele, 338 
treatment of, 342 
Churchill's tincture, 427, 439 
Cicuta, 585, 731 

Cinchona, 156, 293, 305, 306, 398, 473 
Circumdigitation of the uterus, 95 
Clitoris, hypertrophy of, 159 
Cocaine, 195 
Coccyalgia, 798 
Coccygeus muscle, 101 
Coccvgodvnia, 798 
Coccyx, 98, 99, 104 

excision of, 800 

neuralgia of, 798 

subcutaneous division of connections, 
800 
Coffee, 776 
Collodion, 193, 509 
Colocynth, 413 
Colpocele, 182 
Colpotomy, 189 
Columba, 156, 293, 473 
Coma, 347 

Concealed lacerations of perineum, 170 
Condylomata of the vulva, 150 
Congenital atrophy of the ovaries, 682 
Connective tissue, 23, 63, 171, 172, 384, 

448 
Connective-tissue chamber, 23, 25, 35, 49, 
53, 92, 104, 384, 448. See Pelvic con- 
nective-tissue chamber. 
Constipation, 354, 405, 481, 494 
Constrictor cunni muscle, 111 

plane of, 167 
Control of the pelvic floor muscles by the 

will, 37, 85, 102, 186 
Contusions about the bony-walls, 171 



Convulsions, 346, 347, 361 

svncopal, 356 
Copaiba, 229, 245, 248 
Copper sulphate, 152 
Cornil and Ranvier, 593 
Cornus florida, 412 
Corpus uteri, 63 
Corroding ulcer, 155 
Cough accompanying uterine disease, 364, 

365 
Creasote, 248 
Crescent operation, 204 
Emmet's, 205 
Cubebs, 229, 230 
Cupping, 305, 348 
Curette, Byford's finger, 134 

probe, 133 

sharp, 588 

Simon's, 588 

Thomas's wire, 133 
Curetting of the uterus, 133 

for cancer, 585, 589, 595 

in menorrhagia, 306 

in pelvic abscess, 465, 466 

for subinvolution, 570 

exploratory, 133 
Cutter pessary, 507 

Cvstitis. See Inflammation of bladder. 
Cystocele, 182, 479, 480 
Cyst of ovary. See Ovarian tumors. 



Deep pelvic fascia, lacerations of, 168 
Defecation, painful, 347, 361, 454 
Degrees of median laceration of perineum, 

182 . 
Delaved involution, 558 
Delirium, 346 

Delivery after perineal incisions, 192 
Depressor, Sims's, 124 
Dermoid tumors, 697, 750 
Diagnosis of absence of the vagina, 236 

acute inflammation of the unimpreg- 
nated uterus, 347 

acute vaginitis, 244 

atresia vaginse, 237 

amenorrhcea, 286 

between cancer and chronic inflam- 
mation of the cervix (Becquerel's 
summary), 394 

of cancer of the uterus, 577 

cellulitis, 457 

chronic inflammation of the bladder, 
228_ 

chronic ovaritis, 692 

chronic perimetritis, 471 

chronic retrouterine hematocele, 341 

chronic vaginitis, 246 

displacements of the vagina, bladder 
and rectum, 480 

displacements of the ovaries, 684 

differential, of ovarian tumors, 723 

dysmenorrhoea, 309 

endocervicitis, 392 

epithelioma, 592 



808 



GENERAL INDEX. 



Diagnosis of fibrous tumors of the uterus, 

617 
hyperinvolution of the uterus, 570 
hypertrophy of the cervix, 446 
inversion of the uterus, 545 
lacerations of the cervix uteri, 438 
local peritonitis, 463 
membranous dysmenorrhea, 313 
metatithmenia, 334 
obstructive dysmenorrhea, 316 
old lacerations extending into the 

rectum, 184 
ovarian tumors, 714 
paralysis of the bladder, 2"3 
parovarian tumors, 785 
perineal and pelvic floor lacerations, 
177 
by rectal palpation, 181 
by inspection, 183 
lacerations of the pelvic floor : 

a. of the anterior edge, 184 

b. of the levator ani proper, 185 
method of, 186 

retention of menstrual fluid, 288 

salpingitis, 791 

sarcoma, 608 

stone in the bladder, 232 

subinvolution of the uterus, 566 

submucous inflammation of the uterus. 
393 

tumor of the broad ligaments, 785 

uterine disease, 392 

uterine displacements, 495 

during pregnancy, 541 

vaginismus, 242 
Diarrhoea in uterine disease, 354, 355 
Diathesis, hemorrhagic, 300 
Digital eversion of the vagina, 113 

examination through vagina, 58 

exploration of the pelvic roof, 67 
Digitalis, 302 
Dilatation of the urethra, 233 

of the uterus, 128, 326,433 
Dilator : 

Goodell's, 327 

Hanks's, 132, 440, 475, 478, 536 

Hunter's, 312, 327 

Molesworth's, 131 

Peaslee's, 322, 440, 536 

Simon's, 327 

See Tents. 
Diseased deviations of involution of the 

uterus, 558 
Diseases and accidents of the labia and 

perineum, 141 
Diseases of the bladder, 223 

of the vulva, 150 
Displacements of the ovaries, 682 

of the uterus, 484 

of the vagina, bladder and rectum, 
479 
Double perforated catheter (Skene's), 229 
Douches, vaginal, 415, 417 
Douglas, folds of, 18, 49 
Douglas pouch. See Recto-uterine pouch. 



Dover's powder, 311 
Drainage in ovariotomy, primary, 750 
secondary, 751, 782 

after Alexander's operation, 531 

in hysterectomy, 602, 606 
Dressing-forceps, By ford's, 123 
Dumont-Pallier elastic ring pessary, 506 
Duvernev's gland, phlegmon of, 144 
Dysmenorrhea, 308, 330, 339, 375, 615, 
626 

dilatation for, 326. 329 

incision for, 318, 326 

inflammatory form of, 310 
treatment of, 310 

membranous, 312 

neuralgic, 308 

obstructive, 314 

ovarian, 690 

pessary in, 317 

treatment of, 309 
Dysuria, 347, 420, 453 

Ecraseur, 241, 446, 449, 547, 557, 659, 666, 
749 
"Chassaignac's, 660 
Elastic bag, reduction of inversion by, 

555 
Electricity in amenorrhoea, 294 

in hyperinvolution of uterus, 527 

in paralysis of bladder, 225 

in menorrhagia, 305 

in ovarian tumors, 745, 777 

in uterine displacements, 501, 504, 

557 
in uterine fibroids, 654. 657 
treatment of fibrous tumors by, 654 
Apostoli's method of, 655 
Electrolysis. See Electricity. 
Elephantiasis of labia, 148 
Elongation of the supravaginal cervix, 

447 
Elytrorrhaphia duplex lateralis, 217 
Emmenagogues, 290 

Emmet's knife for dividing the cervix, 
319 
method of passing sutures, 214 
method of treating chronic inflamma- 
tion of the bladder, 231 
method of securing the twisted ends 
of silver sutures, 219 
Endocervicitis, 387, 388, 393 

diagnosis of, 392 
Endometritis, 387, 429 
Endosalpingitis, 790 
Endoscope, Skene's, 136 
Enema, 413 

Entero- vaginal fistula, 275 
Entero-vesical fistula, 274 
Enucleation of cyst of the broad liga- 
ment, 785, 794 
of tumors of the uterus, 663, 767 
Enucleator, Sims's, 664 
Epilepsy, 678, 692, 693 

hystero-, 356 
Episiorrhaphy, 509 



GENERAL INDEX, 



809 



Episiotomy, 189 

Epithelial cancer of the uterus, 590 

Epithelioma, 590 

Ergot, contraindications, 568 
corrective treatment, 647 
different preparations of, 644 
in delayed involution, 560, 562 
in inflammation of bladder, 230 
in fibrous tumor of the uterus, 624, 627, 

663, 664, 666 
in membranous dysmenorrhea, 314 
in menorrhagia, 302, 305, 307 
in paralysis of the bladder, 225 
in subinvolution, 568 
mode of using, 642 
modus operandi, 647 

Etiology of uterine disease, 389 

Excrescences, urethral, 157 

Examination of the female pelvic organs, 
53, 55, 114, 138 
bimanual, 57, 59. 65, 68, 74, 77, 80, 93, 

94, 139, 228, 472, 496, 497 
difficulties of. 69 
instrumental, 114 
manner of conducting, 138 
ovaries, 69, 72 
perineum, 108 
position for, 56, 57 
precautions necessary, 63 
preliminaries, 53 
through rectum, 91, 96, 104 
uterus during general anaesthesia, 65 
vaginal orifice, 108 
vulval orifice, 110 

Exsanguinification of uterine tumors, 671 

Fallopian tubes, 27, 67, 68, 330, 732, 789 

absence of, 789 

aspiration of, 795 

cancer and tubercles of, 797 

catheterization of, 795 

cysts of, 797 

deformities of, 789 

differentiation of, 81 

dilatation of, 795, 796 

dropsy of, 797 

extirpation of, 795, 796 

felt through rectum, 95 

hvpertrophv and atrophy of, 749 

inflammation of, 690, 693, 790, 
796 

obliteration of, 796 

palpation of, 67, 68, 77 

positions of, 68 

rudimentary, 789 

rupture of, 239 

sounding, 126 
Female pelvic organs, practical observa- 
tions upon the anatomy and physi- 
ology of, 17 
instrumental examination of, 114 
Fibroid polypus of uterus, 648 

tumors, 610 
Finger curette (Byford's), 134 
Fistula, entero-vaginal, 275 



Fistula, entero-vesical, 274 

recto-vaginal, 275 

urinary, 251 
Fitch's sound, 114 

supporter, 505 

trocar, 765 
Flap lacerations of perineum, 168 

operations upon perineum, 206 
Flattening of the perineal bodv in labor, 

163 
Flexions of the uterus, 489 
Foetal membranes, 161, 187, 188 
Folding of the perineal bodv in normal 

labor, 162 
Follicular vulvitis, 152 

causes of, treatment, 152 
Forceps, double tenaculum, 121 

Nelaton's, 766 

vulsellum, 661 
Foreign bodies in the bladder, 234 
Freund's modified operation upon peri- 
neum, 208 

method of passing sutures, 214 
Fricke (episiorrhaphy), 509 
Fritsch's needle-holder, 526 
Fuller's earth, 505 

Gall-bladder, 772 

Galvano-cautery, 557, 594, 598, 749 

Gangrenous vulvitis, 156 

Gastralgia, 353 

Gastro-hysterotomy, 735 

Gehrung pessary, 512 

Gelsemium, 293, 412 

Gentle touch, advantage of, 67 

Gin, 291 

Glands of Naboth, 430 

Gleet, 790, 792 

Glycerin, 154, 157, 243. 425, 439, 474, 
499, 500, 506, 569, 587, 694, 795 
and tannin, 243 
carbolized, 152 

Gonorrhoea, 151, 246, 349, 390, 445, 690, 
789, 790, 792, 795 

Goodell's dilator, 327 

Goodman-Skene's self-retaiuing catheter, 
135 

Goodman, treatment of chronic inflamma- 
tion of the bladder, 231 

Granular cell of ovarian fluid, 720 

Gray, attachment of the pyriforrais, 100 

Great sacro-sciatic foramen, 100 

Guarded hook, Sims's, 665 

Hsematocele, chronic retrouterine, 338 
peritoneal. See Metatithmenia, 330 

Hanks's dilators, 132, 440 

Hart and Barbour, 207, 211, 212 

Heart, palpitation of, 383 

Hematometra, 796. See Metatithmenia. 

Hemato-salpinx, 796 

Hemorrhagia. See Metrorrhagia. 

Hemorrhage from the bladder, 225 
after the cautery, 596, 597 
from labia, 142 



810 



GENERAL INDEX. 



Hemorrhage in ovariotomv, 750, 767, 769, 

777, 778, 779 _ 
Hemorrhagic diathesis, 300, 779 
Hemorrhoids, 370, 616, 800 
Hemostatic forceps, 604, 605 
Hewitt pessary, 512 
Higby's speculum, 120 
Hip-bath, 228, 247, 290, 305, 311, 349, 416, 

420, 474, 694, 695 
Histologic distinction between sarcoma 

and carcinoma, 608 
Hodge's closed-lever pessary, 521 
Huguier's gland, abscess of, 146 
Hunter's dilators, 327 
Hydatids, 544 
Hydrate of chloral, 403 
Hydrocele, labial, 146 
Hydrometra, 544, 728 
Hydro-sal pinx, 791 
Hymen, 108, 109, 112, 139, 176, 180, 186, 

209, 236, 240, 241, 316, 509 
Hyoscyamus, 421, 585, 586, 731 
Hyperemia, uterine, 383 
Hyperesthesia, 360 

of the bladder and urethra, 325 
Hyperinvolution, 554, 570 
Hypernidation, 312 
Hypertrophied labia, 147 
Hypertrophy of the cervix, 446 

of clitoris and nympha, 159 

of Fallopian tubes, 797 

of ovaries, 682 
Hyrtl, arteries of the pelvis, 52 
Hysterectomy for cancer, 579, 600, 606 

for displacement, 501 

for fibroids, 668 

for sarcoma, 609 

hemorrhage after, 605 

sepsis after, 605 

without ligatures, 604 
Hysteria, 356, 361 
Hystero-epilepsy, 356, 691, 692, 693 
Hysterometer, 118 

method of applying, 119 
Hystero-neuroses, 386 
Hysteropathy, 350, 441, 691 

pathology of, 382 
Hysterophores, 505. See Pessaries. 
Hysterotomy, 549, 756 

for cancer, 600, 665 

for inversion, 549, 556, 557 
Hystero-trachelorrhaphy, See Trache- 
lorrhaphy. 

Ice-bags, 222 

Ice-bladder, 783 

Ice-cap, Thornton's, 782 

Immediate perineorrhaphy, 194 

Indagation, method of rectal, 91 

Indigestion, 242, 398 

Inflammation, acute, of the un impregnated 
uterus, 346 
and ulceration of the cervix, 394 
chronic, of the bladder, 227 
of the vulva, 150 



Inflammatory form of dysmenorrhea, 310 
Infundibulo-pelvic ligament, 73 
Injections, accidents in, 419 

vaginal, 417 
Injuries of the perineum and pelvic floor, 

mechanism of, 161 
Instrumental examination of female pelvic 

organs, 114 
Intramural fibroid tumors, 650 
Intraperitoneal hematocele, 331 
Intra-uterine pessary, Simpson's, 295 

stem-pessary, Jackson's, 536 
Inversion of the bladder, 235 
of the uterus, 543 

mortality, 545, 546 
reduction by the elastic bag, 555 
statistics, 546, 557 
Involution of the uterus, 500 
delayed, 558 

diseased deviations of, 558 
Iodine, 426, 427, 730, 737, 740, 741, 744 
tincture of, 146, 247, 305, 338, 427, 

428, 440, 466, 474, 740 
ointment of, 228, 421 
Iodized phenol, 428 
Iodoform, 195, 196, 198, 221, 505, 531 

gauze, 198, 530 
Ipecac, 311 

Iron, 224, 290, 293, 309, 402, 403, 409, 625, 
799 
by hydrogen, 409 
perchloride, 587 
persulphate, 303, 429, 549, 589 
Quevenne's, 293 
sulphate, 409, 505 

tincture of the chloride of, 154, 155, 
156, 247, 306, 425, 429, 549, 589, 
731 
Irregular lacerations of perineum, 169 
Irritable bladder and urethra, 225 
Ischial spine, 99 

Ischio-rectal vault or fossa, 35, 41, 42, 
104, 122 

Jaborandi, 589 

Jackson's intra-uterine stem, 536 

Jalap, 337 

Jenks's sound, 114 

Jewell, J. S., 49, 352 

Juniper, 229 

Knife for scarifying the cervix, 424 
Kolpokleisis, 268 

Labbe, Dr. Leon, ex-sanguinification of 

tumors of uterus, 671 
Labia, abscess of, 146 

absence of, 149 

adhesions of, 141 

cancer of, 149 

diseases and accidents of, 141 

elephantiasis of, 148 

hemorrhage from, 142 

hydrocele of, 146 

hypertrophy of, 147 



GENERAL INDEX. 



811 



Labia, oedema of, 144 
phlegmon of, 144 
sanguineous infiltration of, 143 
tumors of, 147 
varices of and vulva, 153 
wounds of, 142 
Lacerations of the cervix uteri, 61, 435, 
569 

complications, 437 

degrees, localitv, and duration, 
436 
of the perineum and pelvic floor, 43, 
113, 160 

preliminary observations, 160 

mechanism of, 161 

of coccygeal portion, 161 

of obdurato - coccygeal portion, 
162 

of levator coccygei, 163 

of levator ani proper, 164 

of levator vaginae, 164 

of constrictor cunni, 167 

of vulva, 167 

of trans versus perinaei and sphinc- 
ter ani, 168 

of perineal septum, 168 

of deep fascia, 168 

flap variety of, 168 

central, 169 

irregular, 169 

concealed, 170 
from contusions against bony wall, 171 
extending into rectum, 171 
immediate effects of, 171 
remote effects of, 172 
effects upon uterus, 172 
effects upon bladder, urethra, and 

rectum, 173 
effects upon vagina, 174 
other effects, 1 74 
symptoms of, 174 
varieties of, 175 
degrees of, 176 
diagnosis of, 177 
palpation, 180 
rectal palpation, 181 
inspection, 183 
combined palpation and inspection, 

184 
degrees when extending into rectum, 

184 
diagnosis of lacerations of pelvic floor, 

185 
diagnosis of lacerations of deeper por- 
tions of pelvic floor, 185 
method of diagnosis, 186 
prognosis, 187 
prevention, 187, 192 
colpotomy, episiotomy, 189 
perineal tenotomy, 190 
choice of methods, 192 
treatment, 193 

by coaptation, 193 

immediate perineorrhaphy, 194, 
498 



Lacerations, treatment, reasons for failure, 
194 
contraindications, 194 
the operation, 195 
extending into rectum, 199 
when to operate, 200 
method of restoring the perineum 
when the rectum is not opened. See 
Perineorrhaphy, 
with lacerations of the cervix, 437 
with subinvolution, 569 
Laminaria tents, 128, 129, 132, 231 
Langenbeck's operation, 214 

serres-fine, 217 
Laparo-hysterectomy, 668 
Laparo-oophorectomy, 681 
Laparotomy for adhesions in displace- 
ments of uterus, 517 
extirpation of tumors of uterus, 667 
Lard enema, 732 
Lead acetate, 151, 229, 245, 247 
Leeches, 337, 348, 423, 465 
Lefort's operation for strengthening pelvic 

roof supports, 504, 510 
Leucorrhoea, 371, 379, 388, 392, 395,438, 

480, 545,615, 628 
Levator ani muscle, 101, 108 

plane of, 164 
Levator vagina?, plane of, 164 
Lever for dilating the vagina, 126 
Lewer's, Arthur, ' method of exposing 

ureters, 137 
Ligaments, palpation of the ovarian, 72 
the infundibulo-pelvic, 26, 70, 73 
palpation of the round, 74 
interuretric, 27, 68, 89, 90, 137 
of uterus, 18, 66 
pubo-vesico-uterine, 18, 29, 448, 482, 

487 
sacro-uterine or posterior suspensorv, 
18, 24, 29, 49, 68, 70, 75, 83, 86, 93, 
94, 107, 160, 161, 487, 489, 492, 493, 
494,496,511,512,517,524, 527 
broad, ligamenta lata, 18, 24, 27, 53, 
69. 70,* 74, 76, 81, 82, 95, 107, 160, 
172, 173, 330, 472, 490, 493, 494, 
526, 690, 694, 768, 784, 789, 790, 
792 
round, 19, 27, 68, 74, 76, 84, 85, 172, 
488, 493, 510, 512, 517, 524, 525, 
534 
uterine. See Ligaments of uterus. 
Lime, chloride, 157 
Lithium, 761 

Lithotomy, Sims's method, 233 
Lithotrity, 233 

Liver, sympathetic affections of, 354 
Lobelia,' 302 
Local alteratives, 426 
congestions, 404 
peritonitis, 451, 460 
symptoms of uterine disease, 369 
Location of uterus, abnormal, 63, 64 

normal, 17, 63 
Lymphatics of the pelvis, 25, 53, 68 



812 



GENERAL INDEX. 



Lyttge, tincture of, 276 

Magnesia citrate, 689 

sulphate, 408, 409 
Malgaigne, 509 
Mammary bodies, 366 
Manner of conducting an examination of 
pelvic organs in making a diagnosis, 
138 
Martin's modification of the bilateral opera- 
tion, 203 
Masturbation, 390 
Mayer, elastic ring pessary, 506 
Mcintosh, uterine supporter, 508 
Mechanical support, 517 
Mechanism of laceration and injuries of 

the perineum and pelvic floor, 161 
Median lacerations of perineum, degrees 

of, 182 
Membranous dysmenorrhcea, 312 
Menopause and senility, 343 
Menorrhagia, 297, 377 

from nervous influence, 296, 399 

during lactation, 296 

effect of mammary irritation, 296 

from reflex causes, 296, 297 

from fibrous polypus, 298 

from inflammation, 298, 434, 472 

from malignant disease, 298 

from uterine displacement, 293 

from tumors, 299, 472 

hemorrhagic diathesis, 297 

treatment, 300 

palliative, 301 
curative, 304 
electricity in, 305 
curetting in, 306 

ovarian, 691, 693 

in inversion of uterus, 545. See Me 
trorrhagia 

in cancer, 574 
Menstruation, 276, 278, 330 

increased. See Menorrhagia. 

irregularities, 493 

misplaced. See Metatithmenia. 

rest during, 448 

suppressed. See Amenorrhcea. 
Mercury, 153, 247, 397, 427, 474, 626, 730, 
751, 761 

blue mass, 154, 276. 408 

bichloride, 196, 293, 305, 306, 337, 
398, 473, 646 

cathartic, 157,408 

mild chloride, 244, 311, 348, 689 

ointment, 150 

pernitrate, 428, 598, 600, 601 
Meso-salpinx, 27 
Metatithmenia, 330 

diagnosis, 344, 458 

evacuation of blood in, 337, 339 

prognosis, 335 

sepsis in, 333 

symptoms, 336, 342 
Method of rectal indagation, 91 
Metritis, 347 



Metrorrhagia, 296, 297, 429, 615, 624, 628, 
662 
in cancer, 574, 578, 587 
in delayed involution, 559, 560, 562 
in inversion of uterus, 544, 545, 547, 
549, 554 
Metrotome, Peaslee's, 323 
Microscopic examination of fluid from 

ovarian tumors, 722 
Misplaced menstruation, 330 
Modified Freund's operation, 208 
Molesworth's dilator, 131 
Moral and mental derangement (sympa- 
thetic), 357 
Mucous inflammation of uterus, 387 
Multiparous uterus, appearance of, 126 
Mural salpingitis, 790 
Muscles of pelvis : 

coccygeus, 32, 34, 35, 101, 103 
constrictor cunni, bulbo-cavernosus or 
vulval sphincter, 40. 43,111, 161, 
164. 167, 180, 189, 191, 192, 200 
constrictor urethras, 41 
gluteal, 32, 35 

internal obturator, 32, 70, 103 
levator ani, 29, 32, 33, 34, 35, 42, 90, 
101, 103, 104, 108, 110, 111,162, 
164, 171, 174. 181, 185, 1S7, 189, 
195, 200, 210, 534 
levator vaginas, 29, 34, 40, 42. 43. 90, 
92, 103, 104, 108,110.111,112,115, 
160, 161. 164, 166, 167, 168, 170, 
171, 180, 183, 184, 186, 191, 192, 
200, 201,204, 205,211,242 
psoas, 70 
pyramidal, 32 
piriformis, 35, 57, 99, 101, 103, 105, 

* 106, 108 
sphincter ani, 41, 168, 172, 174, 180, 

181, 182, 210,211, 221 
transversus perinasi, 35, 41, 112, 165, 
166, 168, 180, 192 
Muscular weakness (sympathetic), 362 
Musculature of the pelvic roof, 19 

Naboth glands, 430 

Needle holder, Fritsch's, 526 

Nelaton's forceps, 766 

Nelson's speculum, 120 

Nerves of pelvis, 25, 53, 107, 294, 362, 

616 
Nervous excitabilitv, 401 

prostration, 390, 399 
Neuralgia of the cervix, 798 
Neurasthenia, 352, 685 
Nidation and denidation, 277, 278 
Noma, 156 
Nott's speculum, 120 

tenaculum forceps, 124 
Nnx vomica, 409, 410, 411, 777 
Nympha, hypertrophy of, 159 
Nymphomania, 673 

Oak bark, 506 

Obstructive dvsmenorrhcea, 314 



GENEBAL INDEX. 



813 



Obturato-coccygeus. See Levator ani. 
Obturator internus, 103 
Occlusion of the vagina, 141 
(Edema of the labia, 144 
Oil, almond, 250 

carbolized, 198, 775 

castor, 193, 198, 221, 761 

cod-liver, 247 

olive, 250 
Ointment of belladonna, 248, 411, 421 

calamine, 156 

chloroform, 154 

cicnta, 421 

carbolic acid, 154 

hyoscvamus, 421 

iodine, 228, 421 

mercnrv, 421 

nnt-gafi, 248 

opium, 421 

oxide of zinc, 154 

tannin, 421 
Ointment svringe, 421 
Oldham, 312 
Ooohoralgia, 678 

Oophorectomy, abdominal, 673, 681, 690, 
692, 693 

vagina], 681 
Oophoro-electrolysis, 745 
Oophoro-epilepsy, 678, 691 
Oophoro-mania, 678 
Oophoro-neuroses, 676, 686 
Operating chair, Wilson's, 56 

table, Byford's, 57 
Operation, Battev's, 673 

Bischoff's, 207 

Bozeman's, for vesico-vaginal fistula, 
271 

crescent, upon perineum, 204 

Emmet's crescent, 205 

flap, 206 

for elongation of the supravaginal 
cervix, 449 

for retroversion, 525 

for shortening round ligaments, 527 
sacrouterine ligaments, 525 

Langenbeck's, 214 

ovarian. See Ovariotomy. 

Peaslee's, in obstinate dysmenorrhea, 
320 

Simon's, for vesico-vaginal fistula, 
264 

Sims-Emmet denudation for cystocele 
and procidentia, 502 

Sims's, for dividing straight cervix, 
319 

Sims's, for vesico-vaginal fistula, 255 

star, upon perineum, 205 

to strengthen or elevate the pelvic 
roof supports, 501 

triangular flap, upon perineum, 206 

unilateral flap, upon perineum, 209 
Operation upon uncicatrized lacerations 

of perineum, 210 
Operations, plastic, upon the perineum or 
pelvic floor, 509 



Opium, 199, 276, 301, 336, 348, 402, 420, 
421, 426, 465, 585, 587, 731, 776, 780 

extract of, 151, 154 

tincture of, 548 
Outlines of denudation for procidentia, 

510 
Ovarian cell, 720 

irritation, 689 

ligament, palpation of, 72 

tumors, 695 
Ovaries, 383, 682 

absence of, 289 

acute inflammation of, 688, 713, 793 

atrophy of, 289, 343, 682 

chronic inflamation of, 689, 712 

conditions of, causing menorrhagia, 
296 

enlarged, 528 

extirpation of. See Ovariotomy and 
Oophorectomy. 

hernia of, 684 

how to palpate, 69, 70, 71, 72 

hyperemia of, 690 

hypertrophv, 683 

ligaments of, 26, 27, 70, 72, 77, 78, 81, 
82,95 

location of, 25, 27, 69, 72, 82, 95, 96 

relations of, 25 

table of positions, 72 
Ovariotomy, abdominal, 748 

vaginal, 746 
Ovaritis, acute, 688 

chronic, 689 
Ox-gall. See Beef-gall. 

Palpation of arteries of pelvis, 104, 107 
bimanual. See Bimanual examina- 
tion of ovarian tumors, 716 
of bladder, 96 
of broad ligaments, 81, 83 
of coccygeus muscle, 101 
of constrictor cunni, 111 
of displaced uterus, 63 
of Fallopian tubes, 77 
of infundibulo-pelvic ligament, 72 
of ischial spine, 99 
of levator ani muscle, 101, 108, 110 
of levator vagina?, 108, 110 
of obturator internus, 102 
of old perineal lacerations, 181 
of ovarian ligaments, 72 

tumors, 716 
of ovaries, 69, 72 
of pelvic floor and perineum, 99 
of pelvic floor through rectum, 104 

nerves, 107 

roof, 58 
of perineal body through rectum, 113 
of perineum, 108 
of pregnant uterus, 64 
of pubic fossa, 111 
of pubo-vesico-uterine ligaments, 86 
of pvriformis muscle, 99 
of rectum,91, 96 
of round ligament, 74, 76 



814 



GENERAL INDEX. 



Palpation of sacral promontory, 100 
of sacro-sciatic foramen, 100 
of sacro-nterine ligaments, 83 
of small sacro-sciatic ligaments, 99 
of transversns perinsei, 112 
of ureters, 78, 81 
of uterus, 61, 90 
of vagina, 88, 90 
of vulval orifice, 110 
Paquelin's thermocautery, 594 
Paralysis of the bladder, 223 

ergot in, 225 
Parametritis. See Pelvic cellulitis. 
Parametrium, 25, 86, 87 
Pareira brava, 226, 229 
Parovarian tumors, 784. See Tumor of 

broad ligament. 
Parturition as a cause of disordered invo- 
lution, 558, 567, 568 
of laceration of cervix, 435 
of perineal lacerations, 160, 171 
of uterine displacements, 487, 

498, 511, 546 
of uterine disease, 389 
Pathology of hysteropathy, 382 

of intraperitoneal hematocele, 331 
of periuterine hematocele, 330 
Pawlick, uretral catheterization, 137 
Peaslee's dilators, 440 

elastic ring pessary, 500, 506 
method in obstructive dysmenorrhea, 

320 
metrotome, 323 
Pelvic cellulitis, 228, 274, 298, 348, 390, 
423, 437, 444, 451, 478, 599, 616, 692, 
790 
connective tissue, 23 
connective-tissue chamber, 23, 25, 35, 
49, 53, 92, 104, 384, 448 
Pelvic fasciae, 25, 32, 41, 86, 164, 168 
levator, 181 
perineal, 35, 41, 42, 43 
recto- vesical, 19, 28, 34, 41, 90 
Pelvic floor, 18, 31, 32, 38, 98, 108, 160 
control of muscles by will, 102 
diagnosis of lacerations of, 177, 

184 
effects of lacerations of, 171 
insufficiency, — requirements for 

closing, 38 
mechanism of lacerations and 

injuries of, 161 
lacerations of perineum and, 160 
operation for raising the, 534 
outlet or insufficiencv, 36, 38, 

39, 40, 43, 103, 484 
rectal examination of, 104 
relation of muscles and inter- 
posed tissues, 34 
relation of pelvic roof to, 32 
Pelvic organs, instrumental examination 
of, 114 
percussion of, 58 

practical observations upon the 
anatomy and physiology of, 17 



Pelvic organs, precautions necessary dur- 
ing examination of, 68 
Pelvic peritonitis, 228, 299, 390, 423, 437, 
444, 451, 460, 478, 599, 616, 692, 783, 
790' 
Pelvic roof, digital exploration of, 67 
musculature of, 19 
palpation of, 58 
peritoneal covering of, 22 
plane of, 31 

relation to the pelvic floor, 32 
starting point in examining, 69 
Pepper, black, 293 
Percussion of pelvic organs, 58 
Perimetritis. See Pelvic cellulitis. 
Perineal bodv, 42, 43, 47, 92, 111, 112, 
113, 165, 170, 200, 205, 218 
characteristics of, 43, 112 
flattening of, in labor, 163 
folding of, in normal labor, 162 
measurements of, 42 
rectal palpation of, 113 
incisions, 188 

after-management of, 193 
choice of methods, 192 
delivery after, 192 
lacerations, effects of, 171 
diagnosis of, 177 
palpation of old, 180 
treatment of, 193 
muscular system, 39 
projection or area, 42 
rings, 162, 163, 167, 188 
septum, 41, 164, 168, 181, 182, 200 

lacerations of, 168 
tenotome, 191 
tenotomv, 190 
triangle," 40, 42, 181, 182 
Perineorraphy, immediate, 191 
secondary, 199 
by the median triangular operation, 

" 200 
by the modified triangular operation, 

201 
by the bilateral operation, 202 
by Emmet's crescent operation, 205 
by transverse denudations, 205 
by the star operation, 205 
by the triangular flap operation, 206 
by Bischoff's operation, 207 
by the modified Freund's operation, 

208 
by the crescentic flap operation, 208 
by the unilateral flap operation, 209 
upon uncicatrized lacerations, 210 
for lacerations extending a short dis- 
tance into rectum, 210 
for flap operations, 211 
for lacerations extending high up 

into rectum, 214 
choice of methods, 215 
preparation of patient for, 216 
preparations for operating, 216 
operative detail, 217 
sutures, 218 



GENERAL INDEX. 



815 



Perineorraphy, the quilled suture, 219 
incision of sphincter ani, 221 
after-treatment, 221 
for prolapse, 449, 450, 481 
for retroversion, 534 
Perineum, 18, 39, 46, 63, 108, 124, 160, 
245 249 254 276 
as a support, 44, 160, 449, 450, 480, 

482, 483, 489 
in labor, 45, 46, 160, 222 
operations for raising the, 534 
tendinous raphe* of the, 43, 101, 112, 
113, 160, 164, 165, 166, 170, 171, 
176,180,182,183,191,193,200 
diseases and accidents of, 141 
mechanism of lacerations of, 161 
Perisalpingitis, 790 

Peritoneal covering of the pelvic roof, 22 
Peritoneum, pelvic, 22, 23 
Peritonitis, local, 451, 459 

traumatic, 779 
Pessaries, 439 

Albert Smith's retroversion, 521 
barrier, 518, 520 
Byford's anteversion, 513 

retroversion, 519, 520 
Byrne's stem. 524 
cotton, 519, 537 
Courty's, 519 

Cutter's, 449, 507, 508, 522 
Donaldson's, 524 
Dumont-Pallier's elastic ring; See 

Peaslee's 
egg (Briesky), 507 
Emmet's, 522 
Fitch's, T. D., 519, 523 

supporter, 505 
Fowler's, 500, 523 
Fritsch's modification of Hodge's, 

523 
Gehrung's anteversion, 512 

retroversion, 522 
Hewitt's anteversion, 512 

retroversion, 522 
in constipation, 412, 413 
in dysmenorrhea, 317 
in menorrhagia, 307 
intrauterine, 295 

stem, 515, 536, 523. 524 

in simple dislocations, 499, 
500, 505, 509 
stem, 328, 445, 523, 524, 536, 537 
for anteversion, 512, 514 
for anteflexion, 537, 538 
for prolapse, 449, 481, 505, 509, 

511 
for retroversion, 518, 524, 687 
Hodge's, 500, 507, 531, 536 
Jackson's intrauterine stem, 537 
Kinlock's, 524 
Lazarewitsch's, 509, 522 
Mayer's elastic ring. See Peaslee's 
Mcintosh's, 508 
Noegerath, 522 
Peaslee's elastic ring, 500, 507 



Pessaries, Priestley's, 509, 522 

Koser-Scanzoni hysterophore, 507 

Schroeder's, 522 

Schultze's sleigh, 500, 507, 522 
figure-of-eight, 523 

Scott's, 449, 508, 509, 522 

soft rubber inflated, 499, 506, 517, 544 

Simpson's intrauterine stem, 571 

Sims's, 523 

Studley's retroversion, 523 

Thomas's, 500 

anteversion, 512 
modified Cutter, 507, 508, 522 
bulb retroflexion, 522, 537 
retroflexion, 523, 537 
stem, 524 

traction, 521, 522 

Zwank's, 507 
Phlegmasia alba dolens, 246 
Phlegmon of the labia, 144 
Phosphorus, 309 
Physical culture, 281 

Phvsiologv of the female pelvic organs, 17 
Pinhole os, 376 
Piperine, 777 
Plane of the constrictor cunni, 167 

of the pelvic roof, 31 
Plethora, 404 

with amenorrhcea, 299 

treatment of, 404 
Podophyllum, 413 
Polypoid tumors, removal of, 658 
Position for Simon's speculum, 57 

for Sims's speculum, 57 
Potassium, 626 

acetate, 311, 761 

bromide, 403 

caustic, 155, 600 

chlorate, 413 

iodide, 153, 229, 627, 646, 740 

nitrate, 151, 413 

permanganate, 229, 3*2 
Pouch, para-vesical, 23. 50. 77 

recto-uterine, 22, 27, 48, 66, 73,78, 93, 
339, 340, 341, 668, 687, 715, 718, 
728,751,782,792 

sacral-peritoneal, 23, 92, 93, 107 

vesico-uterine, 22, 86 
Poultices, 465, 795 

charcoal, 157 

mustard, 298 

veast, 157 
Pregnancy, 289, 300, 724, 727 

and cellulitis, 452 

baths and douches during, 420 

extra-uterine, 335, 341, 795 

in uterine disease, 368, 389 

in uterine displacements, 486, 536, 539, 
542 

with fibroid tumors, 620, 621 

with ovarian tumors, 752, 759 

with tubal disease, 797 
Pregnant uterus, palpation of, 64 
Preparation of room for ovariotomy, 761 

of patient, 761 



816 



GENERAL IXDEX. 



Preparation of surgeon, 761 
Pressure, abdominal, 35 

in treatment of ovarian tumors, 737 
Probe curette, 133 

Procidentia, outlines of denudation for, 510 
Prognosis of atresia vagina?, 238 

amenorrhoea, 289 

cancer of uterus, 578 

cellulitis, 459 

chronic ovaritis, 693 

delayed involution, 559 

displacement of ovaries, 685 

dysrxtenorrhcea, 309 

epithelioma, 593 

fibrous tumors of uterus, 619 

inflammation of bladder, 228 

inversion of uterus, 546 

metatithmenia, 335 

obstructive dysrnenorrhoea, 317 

ovarian tumors, 713 

perineal lacerations, 189 

peritonitis, local, 464 

salpingitis, 792 

sarcoma, 609 

subinvolution, 567 

urinary fistula, 253 

vaginitis, acute, 244 
chronic, 246 

vaginismus, 242 
Prolapse and procidentia, 487 
Prolonged lactation, 480 
Pruritus pudendi, 153 

treatment, 154 
Puberty, 278 

Pubic fossa, 111, 112, 117, 180, 181, 186 
Pubo-eoecygeus. See Levator ani. 
Puerile anteflexion, 490 
Puerperal state, immediate effects of lacer- 
ations or those incident to, 171 
Pvemia. See Sepsis. 
Pyo-salpinx, 791, 793 

Quassia, 156, 731 
Quilled suture, 219 

Quinine, 151, 224, 301, 305, 309, 409, 568, 
780, 783, 799 

Rectal examination of pelvic floor, 104 
of pelvic roof, 90 
grooves. See Posterior vaginal sulci, 
indagation, 91. 96 
notches, 30, 109, 110, 186 
palpation, 181 

of the pelvic arteries, 107 
of the perineal bodv, 113 
promontory, 33, 36, 42, 44, 47, 91, 185, 

211 
sphincter. See Levator ani. 
Rectocele, 182, 414, 479, 483 
Recto-vaginal fistula, 249, 250, 275, 276 
grip, 95 

promontory, 103, 109, 110, 181, 
185, 186,' 187, 535 
Recto-vaginal septum, 90, 92, 106, 176, 211, 
212, 214, 215 



Rectum, 29, 31, 33, 36, 42. 46, 52. 58, 59, 62, 
90, 93, 96, 107, 109, 112, 113, 139, 
171, 172, 173, 176, 178, 182, 184, 
185, 199, 210, 215, 219. 221, 222, 226, 
246, 247, 296, 305, 361, 370, 412, 
413, 421, 422, 466, 467, 616. 618, 
776, 778, 780, 792 
abscess opening into, 147, 452, 453, 

475 _ 
dilatation of, 475 
fissure of, 243. 249, 800 

Reduction of inversion by elastic bag, 555 

Reflex symptoms of uterine disease, 352 

Repositor, White's, 551 

Retractors, Simon's, 126 

Retroflexion, 496 

during pregnancy, 539 

Retrouterine hematocele, 338 

Retroversion, 495 

during prearnancv, 537 

Rheumatism. 246, 247 

Rhubarb, 409, 410 

Round ligament, palpation of, 74 

Rubber coil, 787 

Rupture of cyst of broad ligament, 785 

Sacral promontory, 100 

Sacro-sciatic ligaments, 99 

Sacro-uterine ligaments, shortening of, 525 

vaginal palpation of, 83 
Salpingectomy, 795 
Salpingitis, 789, 790, 796 
Sanguineous infiltration of labia, 143 
Sarcoma, 607 
Sarsaparilla, 153, 730 
Savage, muscles of the perineum and pel- 
vic floor, 35, 39 
plane of pelvic roof, 31 
Savin, 290 

Scanzoni pessarv, 507 
Scarificator, 348, 424 
Scarifying the cervix, 424 
Schultze, B. S., figures, 488, 490, 495, 496 

sleigh pessary, 507 
Sciatic and anterior crural nerves, sympa- 
thetic affections of, 362 
Scissors, perineum, 216 

probe-pointed, Byford's, 529 
Scrofula, 246, 247 
Sea-tangle tents, 128, 433, 618 
Secondary perineorraphy, 199 

bilateral operation, 202 

Martin's modification 
of, 203 
median triangular, 200 
modified triangular, 201 
Senilitv, 342, 343 

Sepsis,"333, 342, 453, 466. 527, 641, 662, 
667, 727, 735, 790, 795 
after ovariotomy, 750, 751, 755, 775, 

776, 781 
in cancer, 575, 585, 592, 599, 605, 606 
Septicaemia, 781 
Serrated spoon, Thomas's, 666 
Serres-fines, 216, 217 



GENERAL INDEX. 



817 



Seton, 228, 467, 474 
Sexual intercourse, excessive, 389, 390 
Sharp curette, 588 
Shock, 544, 599, 605, 606, 778, 781 
Shortening of the sacro-uterine ligaments, 
5:25, 527 
dangers of, 526 
Shower bath, 417 
Silk elastic belt, 506 
Silver, nitrate of, 146, 152, 153, 155, 230, 

243, 245, 247, 250, 255, 426, 429 
Simon's curette, 588, 589 _ 

operation for elongation of the supra- 
vaginal cervix, 449 
for closing the vagina, 270 
for vesico-vaginal fistula, 264 
position, 57 
retractors, 126 
speculum, 124 
uretral catheter, 136 
Simpson, Sir J. Y., intrauterine pessary, 295 

sound, 114 
Sims, J. Marion, depressor, 124 
enucleator, 664 
guarded hook, 665 

method of examining the uterus, 127 
of lithotomy, 233 
of treating chronic inflammation 
of the bladder, 231 
operation for dividing straight cervix, 
319 
for elongation of supra-vaginal 

cervix, 449 
for vesico-vaginal fistula, 255 
position, 58 

self-retaining sigmoid catheter, 135 
sound, 114 
speculum, 120, 123 
position for, 57 
treatment of pruritus pudendi, 154 
of vaginismus, 241 
Sitz-bath. See Hip-bath. 
Skene's endoscope, 135 

double perforated catheter, 229 
Slippery-elm tent, 128, 130, 431, 591, 626 
Smith's, Albert, retroversion pessary, 521 
Sodium salts, 626 

borate, 154, 225 
chloride, 413, 426 
nitrate, 413 
Sound, uterine, 1 14 
Fitch's, 114 
Jenks's, 114 
mode of using, 117 
Simpson's, 114 
Sims's, 114 
Thomas's, 114 
Spasms (sympathetic), 361 
Spaying, 673 
Speculum, Higby's, 120 

I Nelson's, 120 
Nott's, 120 
Simon's, 125 
Sims's, 120 



Speculum examination of uterus, 120 
position of patient for, 121 
mode of using, 12 
how to find the os uteri,, 123 
appearance of os, 125, 126 
color, 127 

indications from pus, 128 
conjointly with probe, 128 
with hip-bath, 416 
Sphincter ani, lacerations extending into, 
168 
vaginae, 164 
vulvse, 167 
Spinal cord, sympathetic affections, 360 
Spleen, enlargement in uterine disease, 
355 
injury in ovariotomy, 771 
Sponge bath, 417 
holders, 769 

tents, 128, 129, 231, 240, 303, 304, 445, 
570, 618, 621 
Squibb's ergot, 644 
Stem, Jackson's intrauterine, 536 
Stenosis of the cervix, 431 
of the external os, 323 
of the internal os, 322 
Sterility, 378, 379, 494, 571, 796 
Stillicidium urinse, 540 
Stillingia, 153 
Stomach, functional disturbance of, 353 

sympathy in uterine disease, 353 
Stone in the bladder, 231 
Storer, H. K., abscess of labia, 146 
foreign bodies in bladder, 234 
hysterectomv, 673 
Strychnia, 224, 230, 301, 309, 409, 410, 568 
Subinvolution, 511, 562 
Submucous fibroid tumor, 648 
Subperitoneal chamber. See Connective- 
tissue chamber, 
fibroid tumor, 649 
Sulphur, 761 
Summary of cases of fibroid tumors cured 

by absorption, 641 
Superficial trachelotomy, 322 
Supporter, Fitch's, 505 
Supports of uterus, 18,32 
Suppositories, 413 

Supravaginal cervix, elongation of, 447 
Sutures, 218 

button, 271, 274 

catgut, 195, 197, 199, 219, 526, 530, 

671 
Emmet's method of passing, 214 
flap, 196 

method of introduction, 195, 197, 502 
quilled, 219 
removal of, 198 
silk, 195, 197, 219, 266, 670, 671, 754, 

770 
silkworm-gut, 193, 195, 197, 198, 

199, 219,526, 530 
silver,! 97, 219, 258, 263, 269, 270 # 
Sympathetic or reflex symptons of uterine 
disease, 352 



52 



818 



GENERAL INDEX. 



Sympathetic pains in the pelvic region, 

361 
Syncopal convulsions, 356 
Syphilis, 151, 246, 247, 273, 452 

T bandage, 304 

Table, operating (By ford's), 17 

Tactus eruditus, 68 

Tait, Lawson, flap stitch, 216 

Tamponment vagina?, 512 

Tampons after hysterectomy, 624 

after menorrhagia, 303. 304 

after metrorrhagia, 620 

after ovariotomy, 750 

after uterine displacements, 495, 500, 
506,512,514,516,519,537 

after subinvolution, 5*69 

medicated, 516 
Tannin, 151, 154, 229, 243, 247, 248, 251, 

505, 506, 587 
Tapeworm, 223 
Tapping, 619, 735 

in cyst of broad ligament, 786 

in ovarian tumors, 732, 733, 735, 736, 
739, 744, 752, 756, 760, 765 
Taraxacum, 293 
Tarnier and Chantreuil, 32 
Taylor, Isaac E., 430 
Tenaculum forceps, 121, 124 

Nelson's, 121 
Tenotome, perineal, 191 
Tenotomy, perineal, 190 
Tents, holder, 131 

laminaria, 129 

slippery-elm, 130 

sponge, 129 

tupelo, 128, 129, 132 
Thermocautery, 156, 276, 585, 589, 594, 
598, 599, 668, 749 

dangers of, 596 

Paquelin's, 594, 749 
Thomas, T. G., bulb retroflexion pessary, 
537 

pessary, 512 

serrated spoon, 666 

sound, 114 

wire curette, 133 
Thornton's ice cap, 782 
Tobacco, infusion of, 154 
Torsion of polypoid tumors, 658, 661 

or twisting of the uterus, 493 
Touch, advantages of a gentle, 67 
Trachelorraphy, 440 
Trachelotomy, superficial, 322 
Transverse denudations, 205 
Transversus perinaei, 112 

lacerations extending into, 168 
Traumatic peritonitis, 777 
Treatment of accidents that may occur 
during ovariotomy, 771 

of acute inflammation of the unim- 
pregnated uterus, 348 

of acute vaginitis, 244 

of adhesions in retroversions, 515 

of amenorrhoea, 290 



Treatment of anteversions, 511 

of atresia and absence of the vagina, 

238 
of cancer of the uterus, 579 
of chronic inflammation of the blad- 
der, 228 
method by Goodman, 231 
method by J. L. Papin, 230 
method by Sims, 231 
of chronic ovaritis, 693 
of chronic perimetritis, 473 
of chronic retrouterine haematocele, 

342 
of chronic vaginitis, 247 
of coccygodynia, 799 
of condylomata of the vulva, 150 
of delayed involution, 559 
of displacements of vagina, bladder, 
and rectum, 481 
of ovaries, 685 
of dysmenorrhoea, 309 
of endometritis, 429 
of entero-vaginal fistula, 275 
of entero- vesical fistula, 275 
of epithelioma of the uterus, 594 
of fibrous tumors of uterus, 624 
by electricity, 654 
by enucleation, 663 
by exsanguinification, 671 
surgical, 658 
of follicular vulvitis, 152 
general, of uterine disease, 397 
of inflammation of vulva, 151 
of inflammatory form of dysmenor- 
rhoea, 311 
of inversion of uterus, 546 
of laceration of the cervix uteri, 438 
local, of uterine disease, 422 
of membranous dysmenorrhoea, 314 
of menorrhagia, 300 
of metatithmenia, 336 
of neuralgia of the coccyx, 799 
of obstructive dysmenorrhoea, 317 
of ovarian tumors, 730 
by tapping, 732 
by pressure, 737 
by injection of the sac, 740 
by electrolysis, 745 
by vaginal ovariotomy, 746 
bv abdominal ovariotomy, 

*748 
treatment of the pedicle, 748 

the ligature, 749 
after ovariotomy, 774 
of the wound, 775 
of the vomiting, 776 
of the tympanites, 777 
of the hemorrhage, 778 
of traumatic peritonitis, 779 
of septicaemia, 781 
of parovarian tumors, 786 
of paralysis of the bladder, 224 
of perimetritis, acute, 464 

chronic, 473 
of perineal lacerations, 193 






GENERAL INDEX, 



819 



Treatment of puerperal vaginitis, 244 
of recto-vaginal fistula, 275 
of retroversions, 514 
of retroversion and retroflexion dur- 
ing pregnancy, 541 
of salpingitis, 792 
of sarcoma, 609 
special, of uterine disease, 422 
of stone in the bladder, 233 
of subinvolution, 567 
Triangular ligament, 41, 43 
Trigone, 27, 51, 80, 81, 86, 87, 90 
Trocar, 338, 542, 619, 663, 736, 744, 745, 
753 
Fitch's, 765 
Wells's, 753 
Tubercles of the Fallopian tubes, 797 
Tuberculosis, 275, 285, 486, 797 
Tumors, dermoid, 697, 747 

fibrous, 240, 307, 342, 472, 610, 612, 
674, 676, 678, 680, 715, 724 
origin of, 610, 612 
fibrous, of ovary, 697, 714 

electrolytic treatment of, 654 
medical treatment of, 625 
nature of, 612 
surgical treatment, 659 
varieties of, 611, 614 
of broad ligament, 341, 784, 789 
hvdatid, 727 

ovarian, 332, 335, 341, 695, 724 
pelvic, 486 
Tupelo dilators, 129 

tent, 128, 129, 132 
Turpentine, 229, 293 
Tympanites, 783 

after ovariotomy, 777 



Uncicatrized perineal lacerations, opera- 
tions upon, 210 
Unilateral flap denudations of perineum, 
209 ^ 

operation, 209 
Ureters, after death, 77 

catheterization of, 136, 138 

differentiation of, 81 

inflammation of, 227 

palpation of, 78, 81, 97 

relations of, 27, 28, 68 
Urethra, 29, 30, 87, 90, 97, 135, 137, 142, 
158, 159, 198, 249, 252, 363 

caruncles of, 157 

dilatation of, 96, 233 

vascular, 158 
Urethral excrescences, 157 

fossse, 29, 62, 89, 90, 185, 186, 482, 502, 
503 

notches, 29, 30, 90, 109, 134,185 

speculum and endoscope, 135 
Urethrocele, 479 
Uretral catheter, Simon's, 136 
Urinarv fistula, 251 
Urine, 227, 228, 229 

decomposition of, 224, 228 



Urine, evacuation of, 198, 221, 222, 224, 
243, 250, 347, 454, 466, 517 
fistula, 251, 275 
incontinence of, 135, 225, 478 
retention of, 223, 478, 481, 498, 540 
Uterine disease, general consideration of, 
350 
diagnosis of, 389 
etiology of, 389 

sympathetic reflex symptoms of, 
353 
displacements, 484, 558 

anteversion, 487, 511, 616 
anteflexion, 484, 491 
retroversion, 413, 437, 447, 488, 

514, 616, 739 
retroflexion, 414, 437, 491, 493, 

723, 724 
lapse, 486, 500 
prolapse, 414, 437, 487, 501,511, 

616,739 
protrusion. See Prolapse, 
latero- version, 472, 485, 488, 493 
latero-fiexion, 493 
descent. See Lapse, 
procidentia. See Protrusion, 
torsion, 493 
ante-location, 487 
retro-location, 487 
latero-location. 487 
symptoms, 494 
causes, 486, 493 
what constitutes, 486 
congenital, 492 
diagnosis, 495 
treatment, 498 

by abdominal section, 505 
by cauterization, 504 
by electricity, 501 
by operations upon pelvic 
floor and perineum, 509, 
511 
by operations upon pelvic 

roof supports, 501, 505 
bv operations upon uterus, 

501 
by tampons, 498, 499, 500 
flexions, 536 
hematocele, 330 

manipulations and operations, occa- 
sional outward effects of, 444 
probe. See Uterine sound, 
scarificator and leech (Buttle's), 427 
scissors (Byford's), 441 
sound, 114; 393, 521, 724, 726, 732, 
735 
mode of using, 117 
object in using, 114 
size and length of, 114 
supporter, Mcintosh, 508 
tenesmus, 371 
Uterus, abnormal location of, 63, 472. See 
Uterine displacements, 
abscence of, 289 
acquired atrophy of, 288 



820 



GEXEKAL IXDEX. 



Uterus, acute inflammation of, 346, 389, 
392, 557, 560, 570 
of mucous membrane of, 3-19, 

386, 387 
of unimpregnated, 346 

adhesions of, 395, 472, 617 

appearance of, in the aged, 126 
in the multiparous, 126 

atrophy of, 289, 343, 394, 480 

bimanual palpation of, 65 

cancer of, 394, 572, 606 

chronic inflammation of, 386, 434, 
514, 571 

circumdigitation of, 95 

connected with ovaritis, 694 

delayed involution of, 558 

dilatation of, 128 

displacements of, 61, 64, 71, 73, 76, 
80,81.82, 84, 85, 86, 89, 95,139, 
172, 173, 315, 317, 335, 484, 557, 
687,693,723 

displacements of, as a cause of men- 
orrhagia, 298 

during menstruation, 387 

effects of lacerations upon, 172 

examination of, during anaesthesia, 65 
with sound. 114 

exploratory, curetting of, 13 

fibrous tumors of, 610 

hemorrhage. See Metrorrhagia. 

hyperemia of, 296. 298. 299, 311, 313, 
"379, 383,354. 3S5. 569, 612 

hyper-involution of, 570 

inflammation connected with amenor- 
rhcea, 291, 292 

inversion of, 543 

involution of, 558, 571 

normal location of, 17, 63 

palpation of, 63 

pregnant, 63, 335, 368. See Preg- 
nancy. 

relation to bladder, 31 

replacement of, 514. 515, 541, 542, 
549, 557 

subinvolution of, 562 

tumors of, 610 

ulceration of. See Cervix. 
Uva ursi, 226, 229 

Vagina, 28, 31, 87, 8S, 95, 139, 173, 225, 

236, 448, 791 
abscess discharging into, 452, 453 
absence of, 237, 238 
affections of, 236 
atresia of, 237, 238 
digital e version of, 113, 182, 184 
examination through, 58, 67 
displacement of, 479 
effects of lacerations, 160, 161, 174, 

437 
inflammation of, 225,378, 390, 419 
occlusion of, 141 
palpation of, 88 



Vagina, subinvolution of, 480 

tumors of, 240 
Vaginal douches, 247, 415. 417, 694, 795 
injections, 417. See Vaginal douches. 

accidents in, 419 
orifice, examination of, 108 
ovariotomy, 746 
pack, 516 

palpation of pelvic roof, 98 
of pelvic arteries, 105 
rings. See Perineal rings, 
sphincter. See Levator vaginae, 
sulci or grooves, anterior, 29, 87, 89, 
186, 482, 503 
posterior, 30, 90, 109, 185, 
186, 204 
tamponment, 512 
Vaginismus, 241 
Vaginitis, 225, 378, 390, 453 
acute, 243 
chronic, 245 
puerperal, 248 
Varices of the labia, 143 

of the vulva, 143 
Vascular urethra, 158 
Veratrum, 302, 349 
Versions of the uterus, 4S7 
Vesical calculus, 231 

Vesicovaginal fistula, 227, 231, 249, 251, 
276 
Simon's operation for, 264 
Sims's operation for, 255 
Vesico-vaginal septum, 22, 24, 86, 92, 97, 
138,173,227, 249, 250, 251, 275, 4S2, 
513, 514 
Viburnum, 309 

Vomiting after ovariotomy, 776, 779 
Voracity, 352 

Vulva, condolvmata of, 150 
diseases oif, 150 
inflammation of, 150 
treatment of, 151 
Vulval orifice, examination of, 110 
rings. See Perineal rings, 
sphincter. See Constrictor cunni. 
Vulvitis, follicular, 152 
gangrenous, 156 

Weak back in uterine disease, 360, 370 
Wedlock, 294 
Wells, Spencer, trocar, 753 
White, James P., repositor, 551 
Wilson, H. C. P., operating chair, 56 
Winckel. outlines of denudation for pro- 
cidentia, 510 

palpation of uretral orifices, 97 
Wine, 338 
Wire adjuster, 261 

curette (Thomas's), 133 
Wounds of the labia, 142 



Zwanck's pessary, 501 



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